Publications by authors named "Quynh Doan"

71 Publications

Electrocardiogram in Pediatric Syncope: Practice Variation Among Pediatric Emergency Physicians.

Pediatr Emerg Care 2021 Jun 7. Epub 2021 Jun 7.

From the Division of Emergency Medicine Children's Heart Centre, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada.

Objectives: We intended to assess emergency department physician's practice pattern and their motivations for obtaining electrocardiograms (ECGs) in pediatric vasovagal syncope presentations. We also explored if borderline ECG findings alters emergency department physicians' management in this population.

Methods: We conducted a cross-sectional survey of emergency physicians enrolled in the Pediatric Emergency Research Canada network. The survey questionnaire introduced 2 clinical vignettes presenting a typical vasovagal syncope and a presentation suggestive of a cardiac etiology. Outcome measures included frequency investigations, specialist consultation, and disposition stratified by type of syncope presentation. We also evaluated which specific ECG findings were likely to change physicians' management and explored factors influencing the decision to perform or not perform the ECG.

Results: The analyzable response rate was 47% (105/225). In the low-risk scenario, 51% of respondents requested an ECG, and none consulted the cardiology service, given that all requested investigations are normal. Forty-five percent of physicians modified their management if an ECG was reported as anything but totally normal. In the high-risk scenario, all respondents requested either a 12-lead ECG or a high-lead ECG, and 94% consulted the cardiology service. Physicians also identified clear differences in the motivations behind their decision to perform an ECG in typical vasovagal syncope.

Conclusions: This study highlights the significant practice variation in the evaluation and management of typical vasovagal syncope among physicians, which is informed by complex interactions of patient, provider, and institutional factors and the perceived clinical significance of borderline ECG findings.
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http://dx.doi.org/10.1097/PEC.0000000000002469DOI Listing
June 2021

The utility of universal screening for somatization in a pediatric emergency department: A prospective evaluation.

Clin Child Psychol Psychiatry 2021 May 21:13591045211017619. Epub 2021 May 21.

School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada.

Objective: To evaluate clinical utility and feasibility of universal somatization screening in the pediatric emergency department (ED) using a standardized approach of (1) identifying potential somatizing symptoms within the ED, (2) introducing these patients and their caregivers to the concept of the 'mind-body connection', (3) corroborating the likelihood of a somatization diagnosis via brief psychiatric assessment, and (4) inviting families to a psychoeducational follow-up session.

Methods: We conducted a cross-sectional study to carry out this approach with families visiting a pediatric ED. Our primary outcome of screening utility was measured as the proportion of youth who screened positive for somatization by the ED clinician. Our secondary outcome of screening feasibility was measured as the proportion of patients with positives who (1) agreed to meet with the study psychiatrist, (2) consented to an ED psychiatric assessment, (3) were assessed by the study psychiatrist as likely experiencing somatization, and (4) were invited for follow-up and attended.

Results: Of the 344 screened patients, 27 (7.8%) screened positive for somatization. Of these, 25 (92.6%) families verbally consented to meet the study psychiatrist to learn about the mind-body connection, and 21 (77.8%) consented to further psychiatric assessment. Upon assessment, the somatization likelihood was supported for all 21 youth. Twenty families were invited to follow-up and ultimately two (10%) attended.

Conclusions: Somatization can be detected through ED-based universal screening. Few families attended psychoeducational follow-up. Further research is needed to determine appropriate ED-initiated pediatric somatization intervention.
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http://dx.doi.org/10.1177/13591045211017619DOI Listing
May 2021

Prevalence of Bacterial Meningitis Among Febrile Infants Aged 29-60 Days With Positive Urinalysis Results: A Systematic Review and Meta-analysis.

JAMA Netw Open 2021 May 3;4(5):e214544. Epub 2021 May 3.

Division of Pediatric Emergency Medicine, Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.

Importance: Fever in the first months of life remains one of the most common pediatric problems. Urinary tract infections are the most frequent serious bacterial infections in this population. All published guidelines and quality initiatives for febrile young infants recommend lumbar puncture (LP) and cerebrospinal fluid (CSF) testing on the basis of a positive urinalysis result to exclude bacterial meningitis as a cause. For well infants older than 28 days with an abnormal urinalysis result, LP remains controversial.

Objective: To assess the prevalence of bacterial meningitis among febrile infants 29 to 60 days of age with a positive urinalysis result to evaluate whether LP is routinely required.

Data Sources: MEDLINE and Embase were searched for articles published from January 1, 2000, to July 25, 2018, with deliberate limitation to recent studies. Before analysis, the search was repeated (October 6, 2019) to ensure that new studies were included.

Study Selection: Studies that reported on healthy, full-term, well-appearing febrile infants 29 to 60 days of age for whom patient-level data could be ascertained for urinalysis results and meningitis status were included.

Data Extraction And Synthesis: Data were extracted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and used the Newcastle-Ottawa Scale to assess bias. Pooled prevalences and odds ratios (ORs) were estimated using random-effect models.

Main Outcomes And Measures: The primary outcome was the prevalence of culture-proven bacterial meningitis among infants with positive urinalysis results. The secondary outcome was the prevalence of bacterial meningitis, defined by CSF testing or suggestive history at clinical follow-up.

Results: The parent search yielded 3227 records; 48 studies were included (17 distinct data sets of 25 374 infants). The prevalence of culture-proven meningitis was 0.44% (95% CI, 0.25%-0.78%) among 2703 infants with positive urinalysis results compared with 0.50% (95% CI, 0.33%-0.76%) among 10 032 infants with negative urinalysis results (OR, 0.74; 95% CI, 0.39-1.38). The prevalence of bacterial meningitis was 0.25% (95% CI, 0.14%-0.45%) among 4737 infants with meningitis status ascertained by CSF testing or clinical follow-up and 0.28% (95% CI, 0.21%-0.36%) among 20 637 infants with positive and negative urinalysis results (OR, 0.89; 95% CI, 0.48-1.68).

Conclusions And Relevance: In this systematic review and meta-analysis, the prevalence of bacterial meningitis in well-appearing febrile infants 29 to 60 days of age with positive urinalysis results ranged from 0.25% to 0.44% and was not higher than that in infants with negative urinalysis results. These results suggest that for these infants, the decision to use LP should not be guided by urinalysis results alone.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.4544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8116985PMC
May 2021

Normative and Psychometric Characteristics of the Health and Behavior Inventory Among Children With Mild Orthopedic Injury Presenting to the Emergency Department: Implications for Assessing Postconcussive Symptoms Using the Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5).

Clin J Sport Med 2021 May 11. Epub 2021 May 11.

Werklund School of Education, University of Calgary, Calgary, AB; Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio; Department of Psychology, University of Calgary, Calgary, AB; Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Department of Psychology, Brigham Young University, Provo, Utah; Department of Neurology, University of Utah, Salt Lake City, Utah Department of Psychology, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, QC; Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB; Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC; Department of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON; and Department of Psychology, Alberta Children's Hospital Research Institute, and Hotchkiss Brain Institute, University of Calgary, Calgary, AB.

Objective: The study sought to present normative and psychometric data and reliable change formulas for the Health and Behavior Inventory (HBI), a postconcussive symptom rating scale embedded in the Child Sport Concussion Assessment Tool 5th edition (Child SCAT5).

Design: Prospective cohort study with longitudinal follow-up.

Setting: Pediatric emergency departments (EDs).

Participants: As part of 3 studies conducted in the United States and Canada between 2001 and 2019, 450 children aged 8 to 16 years with mild orthopedic injuries were recruited during ED visits and assessed postacutely (M = 9.38 days, SD = 3.31) and 1 month and 3 months postinjury. Independent variables were rater (child vs parent), sex, and age at injury.

Main Outcome Measure: HBI ratings.

Methods: Children and parents rated children's symptoms at each time point; parents also rated children's preinjury symptoms retrospectively. Normative data (mean, SD, skewness, kurtosis, and percentiles) were computed for child and parent ratings. Internal consistency was assessed using Cronbach alpha (α), and test-retest reliability and interrater agreement were assessed with intraclass correlations (ICCs). Reliable change formulas were computed using linear regression and mixed models.

Results: HBI ratings were positively skewed. Mean ratings and percentiles were stable over time. Child and parent ratings demonstrated good-to-excellent internal consistency (α 0.76-0.94) and moderate-to-good test-retest reliability (ICC 0.51-0.76 between adjacent assessments). However, parent-child agreement was poor to moderate (ICC 0.31-0.69).

Conclusions: The HBI demonstrates acceptable normative and psychometric characteristics. Modest parent-child agreement highlights the importance of multiple informants when assessing postconcussive symptoms. The results will facilitate the use of the HBI in research and clinical practice.
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http://dx.doi.org/10.1097/JSM.0000000000000943DOI Listing
May 2021

Utility of MyHEARTSMAP in Youth Presenting to the Emergency Department with Mental Health Concerns.

J Pediatr 2021 Apr 2. Epub 2021 Apr 2.

Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Objectives: To evaluate the utility of a digital psychological self-assessment tool, MyHEARTSMAP (scores on 10 sections: home, education and activities, alcohol and drugs, relationships and bullying, thoughts and anxiety, safety, sexual health, mood, abuse, and professional resources), in youth presenting to the pediatric emergency department (ED) with a mental health concern.

Study Design: We conducted a prospective cohort study in 2 tertiary care pediatric EDs from December 2017 to October 2019. Youth 10-17 years old triaged for a mental health concern were screened and enrolled to complete MyHEARTSMAP on a mobile device. A clinician blinded to the MyHEARTSMAP assessment conducted their own assessment which was used as the reference standard. Utility was quantified as the sensitivity and specificity of MyHEARTSMAP in detecting psychiatric, social, youth health, and functional concerns.

Results: Among 379 eligible youth, 351 were approached and 233 (66.4%) families were enrolled. Sensitivity for youth MyHEARTSMAP self-assessments ranged from 87.4% in the youth health domain to 99.5% in the psychiatric domain for identifying any concern, and 33.3% in the social domain to 74.6% in the psychiatric domain for severe concerns. Specificity ranged from 66.7% in the psychiatric domain to 98.2% in the youth health domain for no or only mild concerns.

Conclusions: Youth and guardian MyHEARTSMAP assessments are sensitive for detecting psychosocial concerns requiring follow-up beyond pediatric ED evaluation. Specificity for no or only mild concerns was high in the nonpsychiatric domains.
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http://dx.doi.org/10.1016/j.jpeds.2021.03.062DOI Listing
April 2021

Reducing Pediatric ED Length of Stay by Reducing Diagnostic Testing: A Discrete Event Simulation Model.

Pediatr Qual Saf 2021 Mar-Apr;6(2):e396. Epub 2021 Mar 10.

Emergency Medicine Section of Data Analytics, Children's National, Washington, D.C.

Quality improvement efforts can require significant investment before the system impact of those efforts can be evaluated. We used discrete event simulation (DES) modeling to test the theoretical impact of a proposed initiative to reduce diagnostic testing for low-acuity pediatric emergency department (ED) patients.

Methods: We modified an existing DES model, built at another large, urban, academic pediatric ED, to forecast the impact of reducing diagnostic testing rates on mean ED length of stay (LOS). The modified model included local testing rates for Emergency Severity Index (ESI) 4 and 5 patients and additional processes defined by local experts. Validation was performed by comparing model output predictions of mean LOS and wait times to actual site-specific data. We determined the goal reduction in diagnostic testing rates using the Achievable Benchmark of Care methodology. Model output mean LOS and wait times, with testing set at benchmark rates, were compared to outputs with testing set at current levels.

Results: During validation testing, model output metrics approximated actual clinical data with no statistically significant differences. Compared to model outputs with current testing rates, the mean LOS with testing set at an achievable benchmark was significantly shorter for ESI 4 (difference 19.1 mins [95% confidence interval 12.2, 26.0]) patients.

Conclusion: A DES model predicted a statistically significant decrease in mean LOS for ESI 4 pediatric ED patients if diagnostic testing is performed at an achievable benchmark rate compared to current rates. DES shows promise as a tool to evaluate the impact of a QI initiative before implementation.
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http://dx.doi.org/10.1097/pq9.0000000000000396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952107PMC
March 2021

Reducing length of stay and return visits for emergency department pediatric mental health presentations.

CJEM 2021 Jan 10;23(1):103-110. Epub 2020 Dec 10.

Department of Pediatrics, BC Children's Hospital, University of British Columbia, B428B- 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada.

Background: Variability in expertise and risk tolerance among emergency departments (ED) clinicians, when assessing and managing pediatric mental health presentations, leads to increased resource utilization. HEARTSMAP is a validated electronic tool that supports ED clinicians in psychosocial assessments and disposition decision making.

Methods: We used interrupted time series analysis (September 2016-December 2019) and multivariable regressions to measure the impact of integrating HEARTSMAP into ED practice on pediatric mental health presentations length of stay and return visits, at two pediatric EDs. The intervention site used HEARTSMAP trained ED clinicians to assess and manage mental health presentations, and reported bi-weekly ED median length of stay and 30 days-return visits for 15 months and a year, during passive and active implementation of HEARTSMAP, respectively. The control site used psychiatric nurses to assess and manage patients and was only exposed to passive implementation.

Results: HEARTSMAP average uptake was on average 47.4% (range 23.8-74.6%) during active implementation at the intervention site, while the control site showed no uptake throughout the study period. Incremental HEARSTMAP (each percent increase) use was associated with a reduction of 1.8 min (95% CI 0.8-2.9 in ED length of stay and 0.3% (95% CI 0.2-0.5 in 30-day return visit rate. This translates to an adjusted average reduction of 85.3 min in ED length of stay and 15.2% in 30-day return visits for youth with mental health presentations.

Conclusion: Use of HEARTSMAP in the ED can decrease length of stay and return visits for emergency pediatric mental health visits, in a fixed-resource setting.
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http://dx.doi.org/10.1007/s43678-020-00005-7DOI Listing
January 2021

Adaptive randomised controlled non-inferiority multicentre trial (the Ketodex Trial) on intranasal dexmedetomidine plus ketamine for procedural sedation in children: study protocol.

BMJ Open 2020 12 10;10(12):e041319. Epub 2020 Dec 10.

Women and Children's Health Research Institute (WCHRI), University of Alberta, Edmonton, Alberta, Canada.

Introduction: Up to 40% of orthopaedic injuries in children require a closed reduction, almost always necessitating procedural sedation. Intravenous ketamine is the most commonly used sedative agent. However, intravenous insertion is painful and can be technically difficult in children. We hypothesise that a combination of intranasal dexmedetomidine plus intranasal ketamine (Ketodex) will be non-inferior to intravenous ketamine for effective sedation in children undergoing a closed reduction.

Methods And Analysis: This is a six-centre, four-arm, adaptive, randomised, blinded, controlled, non-inferiority trial. We will include children 4-17 years with a simple upper limb fracture or dislocation that requires sedation for a closed reduction. Participants will be randomised to receive either intranasal Ketodex (one of three dexmedetomidine and ketamine combinations) or intravenous ketamine. The primary outcome is adequate sedation as measured using the Paediatric Sedation State Scale. Secondary outcomes include length of stay, time to wakening and adverse effects. The results of both per protocol and intention-to-treat analyses will be reported for the primary outcome. All inferential analyses will be undertaken using a response-adaptive Bayesian design. Logistic regression will be used to model the dose-response relationship for the combinations of intranasal Ketodex. Using the Average Length Criterion for Bayesian sample size estimation, a survey-informed non-inferiority margin of 17.8% and priors from historical data, a sample size of 410 participants will be required. Simulations estimate a type II error rate of 0.08 and a type I error rate of 0.047.

Ethics And Dissemination: Ethics approval was obtained from Clinical Trials Ontario for London Health Sciences Centre and McMaster Research Ethics Board. Other sites have yet to receive approval from their institutions. Informed consent will be obtained from guardians of all participants in addition to assent from participants. Study data will be submitted for publication regardless of results.

Trial Registration Number: NCT0419525.
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http://dx.doi.org/10.1136/bmjopen-2020-041319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733175PMC
December 2020

The knowledge needs for Canadian paediatric emergency physicians in the diagnosis and management of tropical diseases: A national physician survey.

Paediatr Child Health 2021 Jun 30;26(3):e138-e144. Epub 2020 Mar 30.

Department of Pediatrics, University of British Columbia, Vancouver, British Columbia.

Objectives: To assess the knowledge gaps and need for continuing medical education (CME) resources for Canadian paediatric emergency department (PED) physician management of common tropical diseases.

Methods: A cross-sectional survey study of Canadian PED was performed from May to July 2017 using the Pediatric Emergency Research Canada (PERC) database.

Results: The response rate was 56.4% (133/236). The mean performance on the case-based vignettes identifying clinical presentation of tropical illnesses ranged from 59.9% to 76.0%, with only 15.8% (n=21) to 31.1% (n=42) of participants scoring maximum points. Those who 'always' asked about fever performed better than those who only 'sometimes' asked (40.4% versus 23.8%). For management cases, the majority of the participants (59.4% to 89.5%) were able to interpret investigations; however, many were unsure of subsequent actions relating to initial treatment, discharge instructions, and reporting requirements. Many would consult infectious diseases (87.8% to 99.3%). Fifty-three per cent of the participants reported a low comfort level in diagnosing or managing these patients. They rated the importance of CME materials with a median of 50/100, via various modalities such as case studies (71.9%), emphasizing a need for PED-specific content.

Conclusion: This study identified a knowledge gap in the recognition and management of pediatric tropical diseases by Canadian PED physicians. There is a need for formal CME materials to supplement physician practice.
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http://dx.doi.org/10.1093/pch/pxaa022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077208PMC
June 2021

Utility of MyHEARTSMAP for Universal Psychosocial Screening in the Emergency Department.

J Pediatr 2020 04 24;219:54-61.e1. Epub 2020 Feb 24.

Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.

Objectives: To evaluate the utility of universal psychosocial screening in the emergency department (ED) using MyHEARTSMAP, a digital self-assessment and management guiding tool.

Study Design: We conducted a cohort study of youth 10-17 years of age with nonmental health related presentations at 2 pediatric EDs. On randomly selected shifts (December 2017-February 2019), participants completed their psychosocial self-assessments using MyHEARTSMAP on a mobile device, then underwent a standardized clinical mental health assessment (criterion standard). We reported the sensitivity and specificity of respondents' self-assessment, against a clinician's standard emergency psychosocial assessment, and the frequency of psychosocial issues and recommended mental health resources identified by screening.

Results: We approached 1432 eligible youth, among which 795 youth consented to participate (55.5%). Youth and guardians' sensitivity at self-identifying psychiatric concerns was 92.7% (95% CI 89.1, 95.4%) and 93.1% (95% CI 89.5, 95.8%), respectively. In cases where clinicians had determined to be no psychiatric issues, 98.5% (95% CI 96.7, 99.4%) of youth and 98.9% (95% CI 97.3, 99.7%) of guardians identified the youth as having no or only mild issues. Screening identified 36.4% of youth as having issues in at least 1 psychosocial domain which warranted further follow-up.

Conclusions: Psychosocial screening in EDs using MyHEARTSMAP can reliably be conducted using the MyHEARTSMAP self-assessment tool and over one-third of screened youth identified issues which can be directed to further care.
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http://dx.doi.org/10.1016/j.jpeds.2019.12.046DOI Listing
April 2020

Pediatric somatization in the emergency department: assessing missed opportunities for early management.

CJEM 2020 05;22(3):331-337

School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC.

Objective: Somatization is a common phenomenon that can severely complicate youths' functioning and health. The burden of somatization on pediatric acute care settings is currently unclear; better understanding it may address challenges clinicians experience in effectively caring for somatizing patients. In this study, we estimate the prevalence of somatization in a pediatric emergency department (ED).

Methods: We conducted a retrospective cross-sectional study of visits for non-critical, non-mental health-related concerns (n = 150) to a quaternary-level pediatric ED between July 2016 and August 2017. Demographic and clinical visit details were collected through chart review and used by two reviewing clinicians to classify whether each visit had a "probable," "unclear" (possible), or "unlikely" somatizing component.

Results: Approximately 3.33% (n = 5) of youth displayed probable somatization, and an additional 13.33% (n = 20) possibly experienced a somatizing component but require additional psychosocial and visit documentation to be certain. Longer symptom duration and multiple negative diagnostic tests were associated with a higher likelihood of either probable or possible somatization.

Conclusions: A considerable proportion of non-mental health-related visits may involve a somatizing component, indicating the burden of mental health concerns on the ED may be underestimated. A higher index of suspicion for the possibility of somatization may support clinicians in managing somatizing patients.
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http://dx.doi.org/10.1017/cem.2019.477DOI Listing
May 2020

Assessing appropriateness of pediatric emergency department visits: is it even possible?

CJEM 2020 09;22(5):661-664

University of British Columbia, Division of Emergency Medicine, Department of Pediatrics, BC Children's Hospital Vancouver, BC.

Objectives: Numerous studies reported on the frequency of, and factors associated with inappropriate or unnecessary emergency department (ED) visits using clinician judgment as the gold standard of appropriateness. This study evaluated the reliability of clinician judgment for assessing appropriateness of pediatric ED visit.

Methods: We conducted a retrospective cohort study comparing 3 clinicians' determination of ED visit appropriateness with and without guidance from a three-question structured algorithm. We used a cohort of scheduled ED return visits deemed appropriate by the index treating clinician between May 1, 2012, and April 30, 2013. We measured the level of agreement among three clinician investigators with and without use of the structured algorithm.

Results: A total of 207 scheduled ED return visits were reviewed by the primary clinician reviewer who agreed with the index treating clinician for 79/207 visits (38.2%). Among a random subset of 90 return visits reviewed by all three clinicians, agreement was 67% with a Fleiss' Kappa of 0.30 (0.17-0.44). Using a three-question algorithm based on objective criteria, agreement with the index treating provider increased to 115/207 (55.6%).

Conclusions: Although an important contributor to pediatric ED overcrowding, unnecessary or inappropriate visits are difficult to identify. We demonstrated poor reliability of clinician judgment to determine appropriateness of ED return visits, likely due to variability in clinical decision-making and risk-tolerance, social and systems factors impacting access and use of health care. We recommend that future studies evaluating the appropriateness of ED use standardized, objective criteria rather than clinician judgment alone.
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http://dx.doi.org/10.1017/cem.2019.473DOI Listing
September 2020

Assessing appropriateness of pediatric emergency department visits: is it even possible?

CJEM 2020 09;22(5):661-664

University of British Columbia, Division of Emergency Medicine, Department of Pediatrics, BC Children's Hospital Vancouver, BC.

Objectives: Numerous studies reported on the frequency of, and factors associated with inappropriate or unnecessary emergency department (ED) visits using clinician judgment as the gold standard of appropriateness. This study evaluated the reliability of clinician judgment for assessing appropriateness of pediatric ED visit.

Methods: We conducted a retrospective cohort study comparing 3 clinicians' determination of ED visit appropriateness with and without guidance from a three-question structured algorithm. We used a cohort of scheduled ED return visits deemed appropriate by the index treating clinician between May 1, 2012, and April 30, 2013. We measured the level of agreement among three clinician investigators with and without use of the structured algorithm.

Results: A total of 207 scheduled ED return visits were reviewed by the primary clinician reviewer who agreed with the index treating clinician for 79/207 visits (38.2%). Among a random subset of 90 return visits reviewed by all three clinicians, agreement was 67% with a Fleiss' Kappa of 0.30 (0.17-0.44). Using a three-question algorithm based on objective criteria, agreement with the index treating provider increased to 115/207 (55.6%).

Conclusions: Although an important contributor to pediatric ED overcrowding, unnecessary or inappropriate visits are difficult to identify. We demonstrated poor reliability of clinician judgment to determine appropriateness of ED return visits, likely due to variability in clinical decision-making and risk-tolerance, social and systems factors impacting access and use of health care. We recommend that future studies evaluating the appropriateness of ED use standardized, objective criteria rather than clinician judgment alone.
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http://dx.doi.org/10.1017/cem.2019.473DOI Listing
September 2020

Discrete event simulation modelling to evaluate the impact of a quality improvement initiative on patient flow in a paediatric emergency department.

Emerg Med J 2020 Apr 8;37(4):193-199. Epub 2020 Jan 8.

Department of Pediatrics, British Columbia Children's Hospital, Vancouver, BC, Canada.

Objective: We developed a discrete event simulation model to evaluate the impact on system flow of a quality improvement (QI) initiative that included a time-specific protocol to decrease the time to antibiotic delivery for children with cancer and central venous catheters who present to a paediatric ED with fever.

Methods: The model was based on prospective observations and retrospective review of ED processes during the maintenance phase of the QI initiative between January 2016 and June 2017 in a large, urban, academic children's hospital in New York City, USA. We compared waiting time for full evaluation (WT) and length of stay (LOS) between a model with and a model without the protocol. We then gradually increased the proportion of patients receiving the protocol in the model and recorded changes in WT and LOS.

Results: We validated model outputs against administrative data from 2016, with no statistically significant differences in average WT or LOS for any emergency severity index (ESI). There were no statistically significant differences in these flow metrics between the model with and the model without the protocol. By increasing the proportion of total patients receiving this protocol, from 0.2% to 1.3%, the WT increased by 2.8 min (95% CI: 0.6 to 5.0) and 7.6 min (95% CI: 2.0 to 13.2) for ESI 2 and ESI 3 patients, respectively. This represents a 14.0% increase in WT for ESI 3 patients.

Conclusions: Simulation modelling facilitated the testing of system effects for a time-specific protocol implemented in a large, urban, academic paediatric ED, showing no significant impact on patient flow. The model suggests system resilience, demonstrating no detrimental effect on WT until there is a 7-fold increase in the proportion of patients receiving the protocol.
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http://dx.doi.org/10.1136/emermed-2019-208667DOI Listing
April 2020

Provincial dissemination of HEARTSMAP, an emergency department psychosocial assessment and disposition decision tool for children and youth.

Paediatr Child Health 2019 Sep 31;24(6):359-365. Epub 2019 May 31.

Department of Pediatrics, University of British Columbia, Vancouver, British Columbia.

Background: This article describes the provincial dissemination of HEARTSMAP, an evidence-based emergency department (ED) psychosocial assessment and disposition decision tool for clinician use with children and youth.

Methods: HEARTSMAP was disseminated in partnership with local, child and youth mental health teams, as part of a quality improvement initiative implemented in British Columbia EDs. The target audience of education sessions were clinicians working in ED settings responsible for paediatric psychosocial assessments. We used the RE-AIM framework to evaluate the reach, effectiveness, adoption, implementation, and maintenance of HEARTSMAP dissemination, analyzing data from session evaluation forms and online tool data.

Results: Education sessions reached 475 attendees, in 52 of 95 British Columbia EDs. HEARTSMAP training was well received by clinicians with 96% describing effective content including increased comfort in conducting paediatric psychosocial assessments and confidence in disposition planning after training. Clinicians identified unclear processes and lack of local resources as the main barriers to implementation. One-third of the attendees expressed willingness to use the tool, and 27% of registered clinicians have used the tool postimplementation.

Conclusions: Our approach reached and effectively trained clinicians from over half of the province's EDs to use HEARTSMAP for emergency paediatric psychosocial assessments. For some, this provided greater comfort and confidence for these assessments and the following disposition decisions. This evaluation provides valuable insights on training clinicians to use a paediatric mental health tool within diverse ED settings and emphasized the need for ongoing support and institutional engagement to facilitate local, infrastructural, and operational processes for adoption and maintenance, postdissemination.
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http://dx.doi.org/10.1093/pch/pxz038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6735715PMC
September 2019

MyHEARTSMAP: development and evaluation of a psychosocial self-assessment tool, for and by youth.

BMJ Paediatr Open 2019 24;3(1):e000493. Epub 2019 Jul 24.

Pediatrics, University of British Columbia, Vancouver, British of Columbia, Canada.

Background: Paediatric mental health-related visits to the emergency department are rising. However, few tools exist to identify concerns early and connect youth with appropriate mental healthcare. Our objective was to develop a digital youth psychosocial assessment and management tool (MyHEARTSMAP) and evaluate its inter-rater reliability when self-administered by a community-based sample of youth and parents.

Methods: We conducted a multiphasic, multimethod study. In phase 1, focus group sessions were used to inform tool development, through an iterative modification process. In phase 2, a cross-sectional study was conducted in two rounds of evaluation, where participants used MyHEARTSMAP to assess 25 fictional cases.

Results: MyHEARTSMAP displays good face and content validity, as supported by feedback from phase 1 focus groups with youth and parents (n=38). Among phase 2 participants (n=30), the tool showed moderate to excellent agreement across all psychosocial sections (κ=0.76-0.98).

Conclusions: Our findings show that MyHEARTSMAP is an approachable and interpretable psychosocial assessment and management tool that can be reliably applied by a diverse community sample of youth and parents.
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http://dx.doi.org/10.1136/bmjpo-2019-000493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6668754PMC
July 2019

Factors and outcomes associated with paediatric emergency department arrival patterns through the day.

Paediatr Child Health 2019 Aug 27;24(5):323-329. Epub 2018 Dec 27.

Department of Pediatrics, University of British Columbia, Vancouver, British Columbia.

Introduction: Steadily increasing emergency department (ED) utilization has prompted efforts to increase resource allocation to meet demand. Little is known about the distribution and characteristics of patient arrivals by time of day. This study describes the variability and patterns of ED resource utilization related to patient, acuity, clinical, and disposition characteristics over a 24-hour period.

Methods: Retrospective cross-sectional study of all visits to a tertiary children's hospital over a 1-year period. We use descriptive statistics to present ED visit details stratified by shift of arrival, and multivariable regression to explore the association between shift of presentation and hospital admission at index and 7-day return ED visits.

Results: Of 46,942 visits during the study period, 12% arrived overnight, 42% during the day, and 45% during the evening with variability in pattern of shift arrival by day of week. Overnight arrivals had a higher acuity (Canadian Triage and Acuity Scale [CTAS]) and different presenting complaints (more viral infection, less minor trauma) than day and evening arrivals, but similar ED length of stay. Shift of arrival was not associated with admission to hospital, but age, gender, socioeconomic status (SES), and day of week were.

Discussion: ED utilization patterns vary by shift of arrival. Though overnight arrivals represent a smaller proportion of total daily arrivals, their acuity is higher, and the spectrum of disease differs from day or evening arrivals.

Conclusions: Understanding variations and patterns of ED utilization by shift of arrival and day of week may be helpful in tailoring resource allocation to more accurately and specifically meet demands.
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http://dx.doi.org/10.1093/pch/pxy173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6656946PMC
August 2019

Use of a standardized asthma severity score to determine emergency department disposition for paediatric asthma: A cohort study.

Paediatr Child Health 2019 Jul 5;24(4):227-233. Epub 2018 Oct 5.

Faculty of Medicine, University of British Columbia, Vancouver, British Columbia.

Background: We recently introduced a clinical practice pathway for the management of asthma that uses the Pediatric Respiratory Assessment Measure (PRAM) to guide emergency department (ED) treatment and disposition. The pathway recommends discharge for patients who achieve improvement to PRAM <4 at 1 hour after the last bronchodilator. We evaluated practice variation and patient outcomes associated with PRAM-directed disposition recommendations.

Methods: We conducted a retrospective cohort study of children aged 2 to 17 years treated for moderate asthma (PRAM score 4-7) using our asthma clinical pathway. We measured 1) the proportion of children discharged per pathway criteria who returned to our ED within 24 hours and 2) the proportion of children observed beyond the pathway discharge criteria who deteriorated (PRAM ≥4).

Results: We analyzed 385 patient records from September 2013 to February 2015. Among 145 (37.7%) patients discharged per pathway criteria, 4 (4/145; 2.8%) returned within 24 hours. The remaining 240 (62.2%) were observed beyond the pathway discharge criteria; 76/240 (31.7%) had a subsequent deterioration (PRAM score ≥ 4) and 25/240 (10.4%) were hospitalized. Of those who deteriorated, 46/76 (60.5%) worsened within the first additional hour of observation.

Conclusion: We observed significant deviation from our PRAM-directed pathway discharge criteria and that a significant proportion of observed patients experienced clinical deterioration beyond the first hour of observation. We recommend observing children with moderate asthma for 2 or 3 hours from last bronchodilator therapy if PRAM < 4 is maintained, to capture the majority (97.7% or 99.7%) of patients who require further intervention and hospitalization.
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http://dx.doi.org/10.1093/pch/pxy125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6587418PMC
July 2019

The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study.

CMAJ 2019 06;191(23):E627-E635

Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont.

Background: Emergency department overcrowding has been associated with increased odds of hospital admission and mortality after discharge from the emergency department in predominantly adult cohorts. The objective of this study was to evaluate the association between crowding and the odds of several adverse outcomes among children seen at a pediatric emergency department.

Methods: We conducted a retrospective cohort study involving all children visiting 8 Canadian pediatric emergency departments across 4 provinces between 2010 and 2014. We analyzed the association between mean departmental length of stay for each index visit and hospital admission within 7 days or death within 14 days of emergency department discharge, as well as hospital admission at index visit and return visits within 7 days, using mixed-effects logistic regression modelling.

Results: A total of 1 931 465 index visits occurred across study sites over the 5-year period, with little variation in index visit hospital admission or median length of stay. Hospital admission within 7 days of discharge and 14-day mortality were low across provinces (0.8%-1.5% and < 10 per 100 000 visits, respectively), and their association with mean departmental length of stay varied by triage categories and across sites but was not significant. There were increased odds of hospital admission at the index visit with increasing departmental crowding among visits triaged to Canadian Triage and Acuity Scale (CTAS) score 1-2 (odds ratios [ORs] ranged from 1.01 to 1.08) and return visits among patients with a CTAS score of 4-5 discharged at the index visit at some sites (ORs ranged from 1.00 to 1.06).

Interpretation: Emergency department crowding was not significantly associated with hospital admission within 7 days of the emergency department visit or mortality in children. However, it was associated with increased hospital admission at the index visit for the sickest children, and with return visits to the emergency department for those less sick.
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http://dx.doi.org/10.1503/cmaj.181426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6565395PMC
June 2019

Practice Patterns in Pharmacological and Non-Pharmacological Therapies for Children with Mild Traumatic Brain Injury: A Survey of 15 Canadian and United States Centers.

J Neurotrauma 2019 10 17;36(20):2886-2894. Epub 2019 Jun 17.

Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.

Given the lack of evidence regarding effective pharmacological and non-pharmacological interventions for pediatric mild traumatic brain injury (mTBI) and the resultant lack of treatment recommendations reflected in consensus guidelines, variation in the management of pediatric mTBI is to be expected. We therefore surveyed practitioners across 15 centers in the United States and Canada who care for children with pediatric mTBI to evaluate common-practice variation in the management of pediatric mTBI. The survey, developed by a panel of pediatric mTBI experts, consisted of a 10-item survey instrument regarding providers' perception of common pediatric mTBI symptoms and mTBI interventions. Surveys were distributed electronically to a convenience sample of local experts at each center. Frequencies and percentages (with confidence intervals [CI]) were determined for survey responses. One hundred and seven respondents (71% response rate) included specialists in pediatric Emergency Medicine, Sports Medicine, Neurology, Neurosurgery, Neuropsychology, Neuropsychiatry, Physical and Occupational Therapy, Physiatry/Rehabilitation, and General Pediatrics. Respondents rated headache as the most prevalently reported symptom after pediatric mTBI, followed by cognitive problems, dizziness, and irritability. Of the 65 (61%; [95% CI: 51,70]) respondents able to prescribe medications, non-steroidal anti-inflammatory medications (55%; [95% CI: 42,68]) and acetaminophen (59%; [95% CI: 46,71]) were most commonly recommended. One in five respondents reported prescribing amitriptyline for headache management after pediatric mTBI, whereas topiramate (8%; [95% CI: 3,17]) was less commonly reported. For cognitive problems, methylphenidate (11%; [95% CI: 4,21]) was used more commonly than amantadine (2%; [95% CI: 0,8]). The most common non-pharmacological interventions were rest ("always" or "often" recommended by 83% [95% CI: 63,92] of the 107 respondents), exercise (59%; [95%CI: 49,69]), vestibular therapy (42% [95%CI: 33,53]) and cervical spine exercises (29% [95%CI: 21,39]). Self-reported utilization for common pediatric mTBI interventions varied widely across our Canadian and United States consortium. Future effectiveness studies for pediatric mTBI are urgently needed to advance the evidence-based care.
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http://dx.doi.org/10.1089/neu.2018.6290DOI Listing
October 2019

Reliability testing of the HEARTSMAP psychosocial assessment tool for multidisciplinary use and in diverse emergency settings.

Paediatr Child Health 2018 Dec 6;23(8):503-508. Epub 2018 Mar 6.

School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia.

Objective: HEARTSMAP is a tool developed to facilitate assessment and management of paediatric mental health (MH) patients by emergency department (ED) clinicians. We evaluate the inter-rater reliability of HEARTSMAP when administered by clinicians of various backgrounds.

Methods: In a cross-sectional study initiated in 2016, collaborating clinician evaluators (n=16) applied the HEARTSMAP tool to evaluate a set of 50 fictional clinical vignettes, digitally in an approach consistent with the anticipated tool's access and usage in clinical settings. Evaluators came from different types of health centres from across the province of British Columbia (Canada), including remote/rural, regional and urban academic health centres.

Results: We report moderate to near excellent agreement, overall among clinicians for all 10 of the tool's psychosocial sections (κ=0.43 to 0.93) and domain scores (κ=0.75 to 0.90), with acceptable agreement across all tool-triggered service recommendations (κ=0.36 to 0.65).

Conclusions: Our findings show that HEARTSMAP may be reliably used by ED clinicians in assessing MH issues among youth. Results from this study will assist in informing the wider clinical implementation of HEARTSMAP as a standard assessment tool, in diverse emergency care settings.
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http://dx.doi.org/10.1093/pch/pxy017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6242031PMC
December 2018

Management practice-related and modifiable factors associated with paediatric emergency return visits.

Paediatr Child Health 2019 Feb 7;24(1):e1-e7. Epub 2018 Apr 7.

Department of    Pediatrics, BC Children's Hospital Research Institute, University of   British Columbia, Vancouver, British Columbia.

Objectives: We explored practice-related factors associated with preventable unscheduled return visits to an emergency department (RTED).

Methods: We conducted a retrospective cohort study, using standardized review of health records. We included all visits with at least one RTED within 7 days of the index visit. Cases were reviewed by investigators and clinicians to identify: 1) the proportion of unscheduled RTED, 2) the proportion deemed clinically unnecessary and 3) the contribution of clinical practice pattern and system factors.

Results: There were 2809 (7.3%) index visits associated with at least one RTED. Of these, 1983 (70.6%) were unscheduled, 784 (39.5%) were considered clinically unnecessary and 739 out of 784 medically unnecessary RTEDs (94.3%) were attributed to a mismatch between parental expectations and natural progression of disease that did not require Emergency Department (ED) reassessment or interventions. Eighty per cent of reviewed written discharge instructions lacked any anticipatory guidance around symptom range and duration and 21.2% contained instructions to return to the ED for signs and symptoms which do not require ED care. An administrative or system challenge was noted as the reason for the unnecessary and unscheduled RTED in 17.5%. In 3.4% of cases, nonemergency consultants were responsible for the disposition decision and discharge process.

Conclusions: Unscheduled unnecessary return visits to our ED contribute to a significant proportion of our annual volume. Providing discharge instructions that help families distinguish expected range and duration of symptoms from signs requiring ED care was identified as a potential strategy to impact the frequency of unscheduled RTED.
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http://dx.doi.org/10.1093/pch/pxy039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6376311PMC
February 2019

Pediatric Falls: Are Monkey Bars Bad News?

Cureus 2018 Nov 5;10(11):e3548. Epub 2018 Nov 5.

Emergency Medicine, British Columbia Children's Hospital, Vancouver, CAN.

Background Falls are a leading cause of childhood trauma and are the most common mechanism of injury seen in the emergency department (ED). Playground injuries represent a significant fraction of these falls. Objectives This study aims to compare the frequencies of fractures from monkey bars to other types of falls and to explore the statistical associations between the types of injuries. Methods We conducted a cross-sectional study through a retrospective chart review of all British Columbia Children's Hospital ED visits between March 2011 and February 2012. We manually extracted data from ED visits for falls in children two to 17 years of age and used descriptive statistics to report the frequencies of injuries and outcomes. We conducted multivariate logistic regression analyses to compare the odds of fractures associated with various types of falls. Results We reviewed 43,579 ED visits, of which 3,184 (7.3%) were falls. The most common types were from a standing height (42.5%), falls at home (16.2%), and at the playground (14.3%). Peaking in school-age children, these falls resulted in a diagnosis of fracture (37.3%), soft tissue contusion (20.1%), laceration/abrasion (19.4%), and minor head injury (15.8%). We identified 151 falls from monkey bars, among which 64.2% resulted in a fracture. The odds of a fracture following a fall from monkey bars was 3.1 times that of falls from all other causes. Conclusions ED physicians should have a higher suspicion for a diagnosis of fracture if a child reportedly fell from monkey bars. It is warranted to educate parents and educators on the risks associated with the play on these climbing structures.
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http://dx.doi.org/10.7759/cureus.3548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324866PMC
November 2018

In Reply.

Acad Emerg Med 2018 12 2;25(12):1473-1474. Epub 2018 Aug 2.

Division of Emergency Medicine, Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia, Canada.

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http://dx.doi.org/10.1111/acem.13515DOI Listing
December 2018

Reliability of HEARTSMAP as a Tool for Evaluating Psychosocial Assessment Documentation Practices in Emergency Departments for Pediatric Mental Health Complaints.

Acad Emerg Med 2018 12 16;25(12):1375-1384. Epub 2018 Aug 16.

Division of Emergency Medicine, Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia, Canada.

Objectives: The goal of this study was to assess the reliability of HEARTSMAP as a standardized tool for evaluating the quality of psychosocial assessment documentation of pediatric mental health (MH) presentations to the emergency department (ED). In addition, we report on current documentation practices.

Methods: We conducted a retrospective cross-sectional study of pediatric (up to age 17) MH-related visits to four EDs between April 1, 2013, and March 31, 2014. The primary outcome was the inter-rater agreement when evaluating the completeness of pediatric emergency psychosocial assessments using the HEARTSMAP tool. The secondary outcome was to describe the adequacy of documentation of emergency pediatric MH assessments, using HEARTSMAP as a guide for a complete assessment.

Results: A total of 400 medical records (100 from each site) were reviewed. We observed near-perfect inter-rater agreement (κ = 0.99-1.00) regarding the presence of documentation and good-to-perfect agreement (κ = 0.71-1.00) regarding whether sufficient information was documented to score a severity level for every component of an emergency psychosocial assessment. Inter-rater agreement regarding whether referrals or resources were documented for identified needs was observed to be good to very good (κ = 0.62-0.98). Current psychosocial documentation practices were found to be inconsistent with significant variability in the presence of documentation pertaining to HEARTSMAP sections between medical centers and initial clinician assessor and whether specialized MH services were involved prior to discharge.

Conclusions: The HEARTSMAP tool can be reliably used to assess pediatric psychosocial assessment documentation across a diverse range of EDs. Current documentation practices are variable and often inadequate, and the HEARTSMAP tool can aid in quality improvement initiatives to standardize and optimize care for the growing burden of pediatric mental illness.
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http://dx.doi.org/10.1111/acem.13506DOI Listing
December 2018

Using Nurse Practitioners to Optimize Patient Flow in a Pediatric Emergency Department.

Pediatr Emerg Care 2018 Jun;34(6):396-399

British Columbia Children's Hospital.

Objectives: Using nurse practitioners (NPs) in pediatric emergency departments (PEDs) is commonplace in the United States, yet little is known on the impact of NPs on patient flow measures in these environments. This study quantifies the impact of NPs on 2 common measures of patient flow.

Methods: We conducted a retrospective cohort study using administrative data from an academic tertiary care PED. Mean shift length of stay (LOS) and the daily proportion of patients leaving without being seen (LWBS) by a clinician were compared between shifts with and without NPs on duty, matched for external variables affecting the level of activity in the department. Multivariate regression analyses were also conducted to further adjust for covariates such as the total number of PED care providers, patient acuity distribution, and total volume seen in the ED.

Results: Despite a slightly reduced total number of providers present on shifts with NPs on duty, a modest but statistically significant reduction in mean shift LOS (-19.11 minutes [95% confidence interval (CI), -31.01 to -7.22]) and daily proportion of LWBS (-1.11% [95% CI, -1.97% to -0.26%]) was observed for shifts with NPs compared with shifts without NPs on duty. Regression analyses showed that incremental NPs on shift were associated with a decreased LOS (-18.76 minutes [95% CI, -24.51 to -13.02]) as well as a reduced odds of LWBS (odds ratio, 0.56; 95% CI, 0.37-0.87).

Conclusions: Nurse practitioners have a modest impact on patient flow measures in a PED and are a valuable resource to optimize patient flow.
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http://dx.doi.org/10.1097/PEC.0000000000000676DOI Listing
June 2018

System outcomes associated with a pediatric emergency department clinical decision unit.

CJEM 2019 03 15;21(2):195-198. Epub 2018 Apr 15.

*Department of Pediatrics,University of British Columbia,BC Children's Hospital Research Institute,Vancouver,BC.

Objectives: Our objectives were to describe disposition decisions and emergency department return (EDR) rates following a clinical decision unit (CDU) stay; and to determine changes to short stay (<48 hour) hospitalization rates after CDU implementation.

Methods: We conducted a retrospective cohort study of pediatric emergency department (PED) visits with a CDU stay from January 1 to December 31, 2015. Health records data were extracted onto standardized online forms, then used to determine disposition and 7-day EDR rates. Two trained investigators blindly reviewed EDR visits to determine if they were related to the index CDU stay. We compared short stay inpatient admission rates (i.e., hospital length of stay <48 hours) in 2013 and 2015, before and after CDU implementation.

Results: Of 1696 index CDU stays, 1503 (89%) were discharged, and 139 discharged patients (9.2%) had ≥1 clinically-related EDR. Median (IQR) CDU length of stay (LOS) was 4.4 hours (2.7-7.8) and total PED LOS (including CDU) was 7.8 hours (5.4-12.0). Asthma represented 31% of cases. Short stay hospitalization rate decreased from 3.62% in 2013 to 3.23% in 2015 (difference=0.39%; 95% CI=0.15-0.63; p=0.001).

Conclusions: Most CDU patients were discharged, but 9% had a clinically-related ED revisit. CDU implementation was associated with a small but significant reduction in short stay hospitalization.
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http://dx.doi.org/10.1017/cem.2018.57DOI Listing
March 2019

A psychosocial assessment and management tool for children and youth in crisis.

CJEM 2019 01 28;21(1):87-96. Epub 2018 Mar 28.

*Department of Pediatrics,BC Children's Hospital,Vancouver, BC.

Objectives: To evaluate the psychometric properties of HEARTSMAP, an emergency psychosocial assessment and management tool, and its impact on patient care and flow measures.

Methods: We conducted the study in two phases: first validating the tool using extracted information from a retrospective cohort, then evaluating implementation on a prospective cohort of youth presenting with mental health complaints to a tertiary Pediatric Emergency Department (PED). In phase 1, six PED clinicians applied HEARTSMAP to extracted narratives and we calculated inter-rater agreement for referral recommendations using Cohen’s Kappa and the sensitivity and specificity for identifying youth requiring psychiatric consultation and hospitalization. In phase 2, PED clinicians prospectively used HEARTSMAP and we assessed the impact of the tool’s implementation on patient-related outcomes and Emergency department (ED) flow measures.

Results: We found substantial agreement (κ=0.7) for cases requiring emergent psychiatric consultation and moderate agreement for cases requiring community urgent and non-urgent follow-up (κ=0.4 each). The sensitivity was 76% (95%CI: 63%, 90%) and specificity was 65% (95%CI: 55%, 71%) using retrospective cases. During pilot implementation, 62 patients received HEARTSMAP assessments: 46 (74%) of HEARTSMAP assessments triggered a recommendation for ED psychiatry assessment, 39 (63%) were evaluated by psychiatry and 13 (21%) were admitted. At follow-up, all patients with HEARTSMAP’s triggered recommendations had accessed community resources. For those hospitalized for further psychiatric care at their index or return visit within 30 days, 100% were initially identified by HEARTSMAP at the index visit as requiring ED psychiatric consultation.

Conclusions: HEARTSMAP has strong reliability, and when applied prospectively is a safe and effective management tool.
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http://dx.doi.org/10.1017/cem.2018.1DOI Listing
January 2019

Paediatric emergency department overcrowding and adverse patient outcomes.

Paediatr Child Health 2017 Oct 25;22(7):377-381. Epub 2017 Sep 25.

Division of Emergency Medicine, Department of Paediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia.

Background: General emergency department crowding negatively impacts patient care, and increases patient morbidity.

Objectives: This study seeks to determine if markers of paediatric emergency department (PED) flow are independently associated with negative outcomes and increased health care utilization.

Methods: We conducted a retrospective cohort study of PED visits from 2008 to 2012. Data were pulled from an electronic administrative database. Using multivariate logistic regression models, we measured the association between odds of adverse outcomes (hospital/paediatric intensive care unit [PICU] admission, unscheduled return visits and mortality) with markers of PED flow (shift mean length of stay [LOS] and daily rate of patients leaving without being seen [LWBS]).

Results: We found an association between the daily LWBS proportion and the odds of being admitted to the hospital (odds ratio [OR]: 2.1; 95% confidence interval [CI]: 1.2, 3.7), as well as admission to the PICU (OR: 8.9; 95% CI: 1.1, 71.3). We found a statistically significant increase in the odds of admission if seen during shifts in the third or fourth quartile mean shift LOS. We observed lower odds of returning to the PED with increased daily LWBS proportions (OR: 0.4; 95% CI: 0.2, 0.7), but found no association between the odds of returning to the PED and mean shift LOS.

Conclusion: While we found an association between our pre-defined measures of adverse outcomes and markers of PED flow (or crowding), further studies are needed to determine whether PED overcrowding is the cause or effect of increased hospital and PICU admissions.
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http://dx.doi.org/10.1093/pch/pxx111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5804927PMC
October 2017

Constipation and paediatric emergency department utilization.

Paediatr Child Health 2017 Jun 5;22(3):139-142. Epub 2017 May 5.

Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia.

Background: Constipation is a common condition in children. Little is known about the acute health care utilization of constipated children, including how many present to the paediatric emergency department (ED), the spectrum of presenting complaints, investigations and treatments used.

Methods: We conducted a cross-sectional chart review of all 42,875 visits to British Columbia Children's Hospital ED between August 31, 2012 and September 1, 2013. All visits were assessed for a potential diagnosis of constipation and a total of 913 patients were included. We recorded the chief complaints, tests performed and therapies administered in the ED and measures of flow/efficiency including waiting time (WT), length of stay (LOS) and disposition.

Results: Constipation-related visits comprised 2.1% of overall visits. Abdominal pain was found to be the most common presenting complaint in 65.6% of patients; however, 11.9% of patients presented with complaints unrelated to the gastrointestinal tract. Abdominal radiographs were obtained in nearly one-third of patients and almost half of the patients received a fleet enema in the ED. Only a quarter of patients were discharged home on longer-term management. Measures of ED flow were similar between groups, with no meaningful difference in WT or LOS. The vast majority of children (99.7%) were discharged home.

Conclusions: Constipation can be treated as an out-patient, rather than burdening the paediatric ED unnecessarily. This study demonstrates over utilization of radiologic tests and invasive ED treatments and an under utilization of outpatient medication and dietary counselling that may contribute to unnecessary return ED visits.
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http://dx.doi.org/10.1093/pch/pxx041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5804592PMC
June 2017