A comparison of alternative ranking methods in two-stage clinical trials with multiple interventions: An application to the anxiolysis for laceration repair in children trial

BACKGROUND/AIMS

Multi-arm, multi-stage trials frequently include a standard care to which all interventions are compared. This may increase costs and hinders comparisons among the experimental arms. Furthermore, the standard care may not be evident, particularly when there is a large variation in standard practice. Thus, we aimed to develop an adaptive clinical trial that drops ineffective interventions following an interim analysis before selecting the best intervention at the final stage without requiring a standard care.

METHODS

We used Bayesian methods to develop a multi-arm, two-stage adaptive trial and evaluated two different methods for ranking interventions, the probability that each intervention was optimal (Pbest) and using the surface under the cumulative ranking curve (SUCRA), at both the interim and final analysis. The proposed trial design determines the maximum sample size for each intervention using the Average Length Criteria. The interim analysis takes place at approximately half the pre-specified maximum sample size and aims to drop interventions for futility if either Pbest or the SUCRA is below a pre-specified threshold. The final analysis compares all remaining interventions at the maximum sample size to conclude superiority based on either Pbest or the SUCRA. The two ranking methods were compared across 12 scenarios that vary the number of interventions and the assumed differences between the interventions. The thresholds for futility and superiority were chosen to control type 1 error, and then the predictive power and expected sample size were evaluated across scenarios. A trial comparing three interventions that aim to reduce anxiety for children undergoing a laceration repair in the emergency department was then designed, known as the Anxiolysis for Laceration Repair in Children Trial (ALICE) trial.

RESULTS

As the number of interventions increases, the SUCRA results in a higher predictive power compared with Pbest. Using Pbest results in a lower expected sample size when there is an effective intervention. Using the Average Length Criterion, the ALICE trial has a maximum sample size for each arm of 100 patients. This sample size results in a 86% and 85% predictive power using Pbest and the SUCRA, respectively. Thus, we chose Pbest as the ranking method for the ALICE trial.

CONCLUSION

Bayesian ranking methods can be used in multi-arm, multi-stage trials with no clear control intervention. When more interventions are included, the SUCRA results in a higher power than Pbest. Future work should consider whether other ranking methods may also be relevant for clinical trial design.

A low proportion of undertriage validates the new West coast system for triage-Paediatric

AIM

There is a lack of studies on paediatric triage systems. This study aimed to evaluate patient safety of the Gothenburg-developed paediatric triage system West Coast System for Triage-Paediatric (WEST-P).

METHOD

This study was performed at the paediatric emergency department in Gothenburg, Sweden, October 2020 to April 2021. Included patients were double-triaged with the WEST-P, and the established Rapid Emergency Triage and Treatment System-Paediatrics (RETTS-p). We compared the level of urgency between both systems to identify potentially undertriaged patients. Also, we assessed the patient safety according to clinical assessment at presentation, and pre-defined criteria.

RESULTS

This study included 2290 (23%) of triaged patients (44% girls, median age: 5.0 years) during the study period. A higher number of patients triaged to low urgency in WEST-P compared to RETTS-p (p < 0.0001) was observed, and 497 cases with low WEST-P and high RETTS-p urgencies identified. Of these, 29 had a clinical assessment indicating high urgency. After patient safety assessment, seven (0.4%) were determined undertriaged by the new triage system WEST-P.

CONCLUSION

Our findings demonstrate a low risk of undertriage in the new WEST-P. Thus, the WEST-P has a high degree of patient safety when used in a paediatric emergency department.

Determining clinical predictors to identify non-specific abdominal pain and the added value of laboratory examinations: A prospective derivation study in a paediatric emergency department

AIM

To develop a model to discriminate non-specific abdominal pain (NSAP) from organic pain in the paediatric emergency department (PED) and evaluate the added value of laboratory markers.

METHODS

Prospective cohort study in an urban French PED including all patients aged ≥4 years with abdominal pain between November 2020 and May 2021. The outcome was the discrimination between NSAP (patients coded to have only "pain" or "constipation") and organic pain (all other diagnoses) using stepwise backward multivariate logistic regression method with bootstrap resampling.

RESULTS

The study enrolled 246 patients. Overall, 163 patients (66.2%) had NSAP. Four variables associated with organic pain: pain in the epigastric region (OR 0.48 [0.23-0.99]), worsening pain (0.57 [0.32-0.99]), pain migration (0.42 [0.17-0.99]) and vomiting (0.47 [0.26-0.84]) were integrated in a clinical model. To discriminate NSAP with a probability of 65%, model sensitivity was 71.8% (64.9-78.7), specificity was 53.0% (42.3-63.7), and the Net Benefit (NB) was 15.4%. White Blood Count and C-reactive protein results improved discriminative capacity of the model (AUC 0.708 [0.643-0.773] vs. 0.654 [0.585-0.723], p = 0.01) with a supplementary NB of 12%. Patient follow-up showed 95% diagnostic accuracy.

CONCLUSION

This study reveals a four-clinical predictor model with a NB of 15% in predicting NSAP. Validation studies are necessary.

Comparison between local and three validated triage systems in an emergency department for 2126 children under 3 months

AIM

Triage of patients less than 3 months old was not already studied. The aim was to evaluate Paediatric Emergency Department triage in patients less than 3 months old and newborns using a local system in comparison with three validated paediatric triage systems (Canadian Triage and Acuity Scale, Manchester Triage System and Emergency Severity Index) and to determine inter-system agreement.

METHODS

All admissions of patients less than 3 months old admitted to the Emergency Department of the Saint Vincent University Hospital between April 2018 and December 2019 were included. The local triage system level was determined prospectively for comparison with retrospectively calculated triage levels of the validated systems. Hospitalisation rates were compared and inter-system agreements determined.

RESULTS

Among emergency admissions, 2126 were included (55% males, mean age 45 days). Hospitalisation rate increased with priority severity as determined by all triage systems studied. Cohen's kappa showed slight agreement between the local triage system and the Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System (weighted kappa = 0.133, 0.185 and 0.157 respectively).

CONCLUSION

Whether prospective or retrospective triage used, the systems studied exhibited good association with hospitalisation rate for patients aged less than 3 months and newborn infants.

Nasopharyngeal detection of atypical bacteria by multiplex polymerase chain reaction panel in acutely ill children was associated with an increased risk of pneumonia

AIM

We aimed to assess whether detection of respiratory bacteria by multiplex polymerase chain reaction (PCR) testing associates with clinical outcomes in acutely ill children.

METHODS

This cross-sectional study enrolled children under the age of 18 with a suspected respiratory infection treated in a paediatric emergency department of Oulu University Hospital, Finland from January 2015 through December 2015. Nasopharyngeal samples were routinely analysed for 16 respiratory viruses and later, after storage, analysed with a multiplex PCR panel for seven respiratory bacteria.

RESULTS

At least one bacterial pathogen was detected in 600 out of the 1195 children (50%). The mean age was 3.3 (SD 3.7) years and 54% were boys. Atypical bacteria were associated with a risk of pneumonia (adjusted odds ratio [aOR] 14.1, 95% CI 3.98-50.1). Co-detection of rhinovirus with Streptococcus pneumoniae was not associated with risk of pneumonia (aOR 2.39, 95% CI 0.78-7.30). Detection of Streptococcus pneumoniae, Haemophilus influenzae or both was not associated with the risk of hospital admission or prescription of antibiotics.

CONCLUSION

Nasopharyngeal detection of atypical bacteria in acutely ill children was associated with a markedly increased risk of pneumonia. The clinical utility of wide testing for other respiratory bacteria needs further evaluation.

COVID-19 increased in Italian children in the autumn and winter 2021-2022 period when Omicron was the dominant variant

AIM

We examined the prevalence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in children during the autumn and winter season from 1 September 2021 to 30 January 2022 and compared it with the same period in 2020-2021.

METHODS

This study was carried out int the paediatric emergency department (PED) of a tertiary Italian hospital. We compared the clinical and demographical features of all children who presented during the two study periods and tested positive for SARS-CoV-2.

RESULTS

During the 2021-2022 autumn and winter season 5813 children presented to the PED, 19.0% were tested for SARS-CoV-2 and 133 (12.0%) of those tested positive. In 2020-2021, 2914 presented to the PED, 12.3% were tested, and 30 (8.3%) of those tested positive. There were no statistically significant differences in clinical severity during the two study periods, despite a higher percentage of neurological symptoms in 2020-2021. Of the SARS-CoV-2-positive cases, 29/133 (21.8%) were hospitalised during the 2021-2022 season and 10/30 (33.3%) during the previous one. Only 3/163 children required intensive care.

CONCLUSION

The greater spread of SARS-CoV-2 was probably due to the greater transmissibility of the Omicron variant, but the symptoms were mild and only 3 children required intensive care.

Identification of sepsis in paediatric emergency departments: A scoping review

AIM

Sepsis is an acute illness associated with significant morbidity and mortality. Early detection and time-sensitive management of sepsis has been shown to improve outcomes. We report the results of a scoping review to explore methods evaluated for the identification of sepsis in children presenting to emergency departments.

METHODS

A systematic literature search was carried out on two databases, Medline and Web of Science, to identify relevant studies published from 1990 to 2022. Data were extracted for age groups including study design, reference standard used for comparison, sepsis identification method evaluated and study quality.

RESULTS

A total of 89 studies were identified from the literature search. There was significant heterogeneity in the age groups including study design and reference standards used for evaluating the performance of the sepsis identification methods. There has been a substantial increase in the number of published studies in the last 2 years.

CONCLUSION

Our scoping review identifies marked heterogeneity in approaches to identifying sepsis but demonstrates a recent focus of research on patient outcomes. Using appropriate core outcome sets, developing reference standards, monitoring sepsis prevalence via registries and continuously monitoring process measures will provide robust evidence to identify the best performing identification tools and the impact they have on patient-orientated outcomes.

The first winter of social distancing improved most of the health indexes in a paediatric emergency department

Aim

We compared visits to a tertiary level paediatric emergency department (PED) in Italy, during winter 2020–2021, when COVID‐19 social distancing measures were in place, with winter 2019–2020.

Methods

This was a retrospective analysis of an electronic database. We obtained the number of visits and the ages, main complaints, triage codes, discharge diagnoses and outcomes of patients who accessed the PED from the 1 October 2020 to 28 February 2021. These were compared to the same period in 2019–2021.

Results

Visits fell by 52%, from 10982 in 2019–2020 to 5317 in 2020–2021 (p < 0.0001). The reductions were 52% in neonates, 58% in infants, 53% in toddlers, 61% in preschool children, 48% in school children and 46% in adolescents. Non‐urgent and urgent triage codes declined. Respiratory and gastrointestinal infections fell by 72% and 71% respectively. Injuries declined by 42%, mainly among adolescents. Accidental intoxication, psychiatric symptoms and substance or alcohol abuse declined by 24%, 33% and 64%. Hospital admissions reduced by 8% and admissions to intensive care fell by 29%.

Conclusion

During the first winter of pandemic social distancing visits to an Italian PED fell by 52%, with higher reductions in younger children and infants, and hospital admissions fell by 8%.

Paediatric Antimicrobial Stewardship for Respiratory Infections in the Emergency Setting: A Systematic Review

Antimicrobial resistance occurs due to the propensity of microbial pathogens to develop resistance to antibiotics over time. Antimicrobial stewardship programs (ASPs) have been developed in response to this growing crisis, to limit unnecessary antibiotic prescription through initiatives such as education-based seminars, prescribing guidelines, and rapid respiratory pathogen (RRP) testing. Paediatric patients who present to the emergency setting with respiratory symptoms are a particularly high-risk population susceptible to inappropriate antibiotic prescribing behaviours and are therefore an ideal cohort for focused ASPs. The purpose of this systematic review was to assess the efficacy and safety of ASPs in this clinical context. A systematic search of PubMed, Medline, EMBASE and the Cochrane Database of Systematic Reviews was conducted to review the current evidence. Thirteen studies were included in the review and these studies assessed a range of stewardship interventions and outcome measures. Overall, ASPs reduced the rates of antibiotic prescription, increased the prescription of narrow-spectrum antibiotics, and shortened the duration of antibiotic therapy. Multimodal interventions that were education-based and those that used RRP testing were found to be the most effective. Whilst we found strong evidence that ASPs are effective in reducing antibiotic prescribing, further studies are required to assess whether they translate to equivalent clinical outcomes.

Children discharged from an emergency department with bacteraemia had lower C-reactive protein and better outcomes than admissions

AIM

To investigate whether there are common clinical findings in bacteraemic children that were discharged from the emergency department (ED) and to follow their clinical outcome.

METHODS

A retrospective chart review of children above one-month-old with positive blood cultures obtained in Shamir Medical Center's ED between January 2011 and December 2019 was conducted.

RESULTS

A total of 250 cases were analysed, of which 68 discharged after first evaluation. Streptococcus pneumonia was the most commonly isolated pathogen. Compared to children that were admitted when first evaluated in the ED, discharged children had lower C-reactive protein (mean 50.5 ± 62.8 vs 121.7 ± 113.2 mg/L, p < 0.001). Dyspnoea and being ill-looking were less prevalent among the latter (6.7% versus 35.1%, p = <0.001, 3.0% versus 22.2% p < 0.001, respectively), as were presence of Kingella kingae and other Gram-negative bacteria. Of the children hospitalised in our institution, the duration of hospitalisation was significantly lower than in those admitted during the first visit (6.3 ± 4.3 vs 9.0 ± 7.4 days, p = .002). None of the discharged children were admitted to paediatric intensive care unit.

CONCLUSION

Children with bacteraemia who were discharged home before knowing their positive blood cultures results had lower C-reactive protein and better outcome compared to those admitted on first evaluation in emergency department.

A Procalcitonin and C-Reactive Protein-Guided Clinical Pathway for Reducing Antibiotic Use in Children Hospitalized with Bronchiolitis

Despite the lack of evidence that bronchodilators, corticosteroids, and antibiotics are useful in treating bronchiolitis, their use is still widespread. This study aimed to determine the consumption of antibiotics for bronchiolitis before and after a procalcitonin-guided clinical pathway (CP) implementation. In December 2019, a CP for lower respiratory tract infection management was implemented at the Department of Women's and Children's Health at Padua University Hospital. This was a pre-post, quasi-experimental study that assessed the changes in the treatment of bronchiolitis during two bimesters preceding the CP implementation (pre-period: January 2018-February 2018 and January 2019-February 2019) and during the bimester after CP implementation (post-period January 2020-February 2020). After the CP implementation, there was a significant reduction in antibiotic prescriptions from 36.2% to 12.5% (p = 0.036) in patients hospitalized for bronchiolitis. Co-amoxiclav treatment, the antibiotic most commonly administered, decreased from 66.6% to 33.3%. Among outpatients' bronchiolitis episodes, a statistically significant decrease in beta2-agonists' use (from 18.0% to 4.4%, pre and post periods) and a quasi-significant decrease in corticosteroid use (from 8.0% to 0% pre and post periods) were observed. An evidence-based CP supported by educational lectures was associated with significant changes in the physicians' prescribing habits.

Semi-automatic intraosseous device (EZ-IO) in a paediatric emergency department

AIM

Intraosseous access is an alternative to conventional intravenous access. A number of studies have demonstrated the utility and safety of EZ-IO, a recently introduced semi-automatic intraosseous device. However, few studies have investigated the use of EZ-IO in the paediatric emergency setting. The aim of this study was to describe the epidemiological characteristics EZ-IO use including complications among paediatric patients in a paediatric emergency department.

METHODS

We conducted a retrospective descriptive study enrolling children younger than 16 years who visited our emergency department between January 2013 and August 2018. Data on age, gender, diagnosis, insertion success rate and complications were collected and analysed.

RESULTS

Seventy-two patients were enrolled; of these 38 (52.8%) were male. The median age was 9 months (interquartile range: 3-34.5 months). Of the total, 22 (30.6%) received more than one IO insertion. Ninety-seven consecutive IO insertions were identified. The rate of successful insertions was achieved at 92.7% (90 insertions). There were 21 complications (21.6%), including 17 extravasations (17.5%) of fluid and four dermal abrasions (4.1%). We found no cases of complications that may have compromised patient safety.

CONCLUSIONS

The success rate of the EZ-IO insertion was high in paediatric patients. However, we found a higher incidence of dermal abrasions, which might be a complication specific to children.

Does location of rapid influenza diagnostic testing influence treatment time and ancillary testing in a paediatric emergency department?

OBJECTIVE

Influenza causes a significant burden of disease. Our aim was to assess whether location of rapid influenza diagnostic testing (RIDT) for patients with influenza-like illness (ILI) has an impact on ED treatment time or ancillary testing.

METHODS

This was a retrospective observational study in a tertiary paediatric ED during 2017 influenza season. All patients with ILI were included. Some had RIDT performed (ED bedside or at the laboratory). Primary outcome measure was the correlation of RIDT location to treatment time compared to patients with ILI with no RIDT. Secondary outcome measures were the correlation of RIDT location to ancillary testing and treatment with antibiotics.

RESULTS

A total of 1451 patients with ILI were included. Eighty patients for whom RIDT was performed at the laboratory had a shorter treatment time in the ED when compared to the 215 patients for whom RIDT was performed bedside (2.8 and 3.4 h, respectively; P < 0.0001). However, treatment time was not statistically different when sub-analysed for admitted and discharged patients separately. Overall, patients with ILI and no RIDT had the shortest treatment time in the ED (1.7 h). There was no difference in ancillary testing and treatment with antibiotics between ILI patients for whom RIDT was performed bedside or at the laboratory regardless of admission.

CONCLUSION

Location of RIDT may not have a significant impact on treatment time, ancillary testing and treatment with antibiotics. When RIDT was not performed, patients had the shortest treatment time.

Traumatic dental injuries presenting to a paediatric emergency department in a tertiary children's hospital, Adelaide, Australia

BACKGROUND/AIM

There is a scarcity of data regarding paediatric traumatic dental injuries (TDI) in tertiary teaching hospitals. Therefore, the aim of this study was to review the TDI presenting to the Women's and Children's Hospital in Adelaide (Australia) on an emergency basis and to identify the characteristics of the presenting patient cohort, their accident, injuries and management.

METHODS

Medical health records of 337 paediatric patients attending the Paediatric Emergency Department (PED) for the management of TDI over 18 months were prospectively reviewed.

RESULTS

TDI were more frequent in children under 5 years of age (56.1%) with a predominance of injuries sustained by males (63.8%). The accident characteristics included weekend occurrence (35.6%), the most common aetiology was falls (64.4%) and many incidents occurred at home (48.5%). Overall, 654 teeth were injured with the majority affecting deciduous teeth (58.4%) and the maxillary central incisors (69.9%). The most frequent injury was lateral luxation (27.5%). The majority of patients were referred to the Paediatric Dentistry Department (60.8%). However, almost half of presenting patients did not require further management locally and were subsequently discharged to their dental practitioners (39.2%). Most patients receiving treatment were managed under general anaesthetic (36.9%), and there was often a delay of 3-12 hours before treatment commenced (49.1%). Similarly, more severe injuries in the permanent dentition (avulsion, extrusion, root fracture, intrusion, alveolar fracture) were more frequently managed between 3 and 12 hours following the accident.

CONCLUSION

The patient, accident, injury and management characteristics are comparable to what has previously been reported in other studies in paediatric populations. Injuries affecting the permanent dentition are more likely to be managed within 3 and 12 hours in an outpatient setting, whereas injuries affecting the deciduous dentition had a delay in management between 12 and 24 hours under general anaesthetic.

Predictors of clinically urgent intracranial pathology at neuroimaging in children with complex febrile seizures: a retrospective cross-sectional study

AIM

To assess the prevalence of clinically urgent intracranial pathology (CUIP) in children visiting the emergency department with a complex febrile seizure (CFS).

METHODS

Retrospective cohort review. We analysed the visits of patients for a CFS from January 2007 to December 2011 in seven paediatric emergency departments. Our main outcomes were the proportions of CUIP diagnosed between day 0 and 1 and within 30 days after the index visit.

RESULTS

From 1 183 487 visits, 839 were for a CFS and 130 (15.5%) of these had a neuroimaging performed within 30 days (CT scan for 75 visits [8.9%], MRI for 30 visits [3.6%] and both for 25 visits [3.0%]). Three CUIP were diagnosed between day 0 and 1 (0.4% [CI-95%: 0.1-1.3]), 5 within 30 days after the index visit (0.7% [CI-95%: 0.2-1.7]) but none among the 630 visits of children presenting with a normal neurological clinical examination (0% [95% CI: 0.0-0.7]), nor among the 468 presenting only with multiple seizure (0% [95% CI: 0.0-1.0]).

CONCLUSION

In children with a CFS, CUIP is rare event in the subgroup of children with a normal neurological clinical examination and in those with brief generalised multiple seizures.

Education, decision support, feedback and a minor reward: a novel antimicrobial Stewardship intervention in a Swedish paediatric emergency setting

Background: Sweden enjoys a favourable situation with regard to antimicrobial resistance. However, healthcare costs are expected to increase exponentially, along with increased morbidity and mortality, due to the emergence of resistant bacterial strains. Our aim was to design an antimicrobial stewardship programme suitable for Scandinavian settings. Methods: A quasi-experimental pre-post study was conducted in a Swedish paediatric emergency department, evaluating adherence to national guidelines for acute otitis media and acute tonsillitis. The programme consisted of educational outreach, decision support, feedback, and a minor reward upon reaching a pre-defined adherence rate. Results: The largest impact, significant for both diagnoses, was on the practice of refraining from antibiotic use when recommended. The other variables evaluated showed no significant improvement for either condition; however, in most cases, pre-interventional adherence was already high. Conclusions: This relatively easily implementable ASP intervention showed a significant effect on correctly refraining from the use of antibiotics. Previous interventions in Scandinavia either failed to accomplish this or have been more logistically difficult. The combination of education, decision support, email-based feedback and a minor reward, offers an alternative. Future research will be needed to assess whether the result is sustainable, as well as to identify additional barriers to the judicious use of antibiotics not addressed in this study.

[Systemic approach: improving patient management in paediatric emergency departments]

The main mission of paediatric emergency departments is to assess the health status of children and perform a triage depending on their pathology. The role of the children's health nurse is essential for delivering the care but also for constructing, with the young patient and the family, a relationship of trust. To do so, she uses her knowledge and expertise to support these vulnerable families.

Soap bubbles as a distraction technique in the management of pain, anxiety, and fear in children at the paediatric emergency room: A pilot study

BACKGROUND

Hospitals can cause anxiety, pain, and fear in children perceiving medical procedures as intrusive and painful. Among the nonpharmacological strategies, distraction techniques have proved to be effective in the management of pain and distress.

METHODS

The aim of the present study is to assess the effectiveness of soap bubbles as a distraction technique for the management of anxiety, fear, and pain in children waiting for a medical examination at the paediatric emergency room. We employed a parallel trial design with a sample consisting of 74 children (M = 9.30; SD = 1.10; 50% female) randomly assigned to either a control or experimental group. The children in the experimental group underwent the soap bubble protocol while waiting for a medical examination at the paediatric emergency room. Anxiety, fear, and pain were assessed by self-report administered to the children before the triage and the application of the soap bubbles (baseline), after the application of the soap bubbles (T1), and after the medical examination (T2).

RESULTS

The children in the experimental group showed a significant reduction of perceived pain while waiting for the medical examination (T1), whereas no difference was found after the medical examination (T2). Furthermore, the children in the experimental group showed a significant reduction in fear (T1 and T2), whereas no difference was found in the anxiety scores measured by the Child Anxiety.

CONCLUSION

The use of soap bubbles is a good distraction technique in the reduction of fear and the perception of pain in children awaiting a medical examination at the paediatric emergency room.

[Newborn consultations in paediatric emergency departments]

More and more newborns are being taken to paediatric emergency departments in France. A study was carried out between 2013 and 2015 to identify the reasons for non-emergency consultations, and to analyse the risk factors. The most common diagnoses were: rhinitis, gastro-oesophageal reflux and colic. There were three main predictive factors for consultation: the young age of the mother, primiparity and the short stay in the maternity hospital.

[Acceptability of the systematic screening of suicidal adolescents in emergency departments]

Studies of adolescent suicide screening tools have increased with the development of questionnaires that can be used in paediatric emergency departments. This article proposes a literature review of the acceptability of such interventions. Although these tools are well accepted when they are systematized, their usefulness is determined by the availability of child psychiatric care with the right balance between the adolescent's confidentiality and parental involvement.

Caring for children with autism spectrum condition in paediatric emergency departments

The needs of children with autism spectrum condition (ASC) in paediatric emergency departments (EDs) can often be overlooked. EDs are high-stress environments for children with ASC, which can result in meltdowns, making the diagnostic process challenging. There should be provision for children with ASC, who can have sensory, behavioural and communication needs, in the same way that analgesia is provided for children in pain. This article promotes a multi-strategy approach to making reasonable adjustments to help meet the needs of these children and provide them with a positive hospital experience.

Development and feasibility testing of the Pediatric Emergency Discharge Interaction Coding Scheme

Background

Discharge communication is an important aspect of high‐quality emergency care. This study addresses the gap in knowledge on how to describe discharge communication in a paediatric emergency department (ED).

Objective

The objective of this feasibility study was to develop and test a coding scheme to characterize discharge communication between health‐care providers (HCPs) and caregivers who visit the ED with their children.

Design

The Pediatric Emergency Discharge Interaction Coding Scheme (PEDICS) and coding manual were developed following a review of the literature and an iterative refinement process involving HCP observations, inter‐rater assessments and team consensus.

Setting and participants

The coding scheme was pilot‐tested through observations of HCPs across a range of shifts in one urban paediatric ED.

Main variables studied

Overall, 329 patient observations were carried out across 50 observational shifts. Inter‐rater reliability was evaluated in 16% of the observations. The final version of the PEDICS contained 41 communication elements.

Results

Kappa scores were greater than .60 for the majority of communication elements. The most frequently observed communication elements were under the Introduction node and the least frequently observed were under the Social Concerns node. HCPs initiated the majority of the communication.

Conclusion

Pediatric Emergency Discharge Interaction Coding Scheme addresses an important gap in the discharge communication literature. The tool is useful for mapping patterns of discharge communication between HCPs and caregivers. Results from our pilot test identified deficits in specific areas of discharge communication that could impact adherence to discharge instructions. The PEDICS would benefit from further testing with a different sample of HCPs.