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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.

Objective: Return visits to the emergency department (RTED) for the same clinical complaint occur in 2.7% to 8.1% of children presenting to pediatric emergency departments (PEDs). Most studies examining RTEDs have focused solely on PEDs and do not capture children returning to other local emergency departments (EDs). Our objective was to measure the frequency and characterize the directional pattern of RTED to any of 18 EDs serving a large geographic area for children initially evaluated at a PED., Methods: We conducted a retrospective cohort study of all visits to a referral centre PED between August 2012 and August 2013. We compared demographic variables between children with and without an RTED, measures of flow and disposition outcomes between the initial (index) visit and RTED, and between RTED to the original PED versus to other EDs in the community., Results: Among all PED visits, 7.6% had an RTED within 7 days, of which 13% were to a facility other than the original PED. Children with an RTED had higher acuity and longer length of stay on their index visit. They were also more likely to be admitted on a subsequent visit than the overall PED population. RTED to the original PED had a longer waiting time (WT), length of stay, and more frequently resulted in hospitalization than RTED to a general ED., Conclusions: A significant proportion of RTED occur at a site other than where the original ED visit occurred. Examining RTED to and from only PEDs underestimates its burden on emergency health services.

Objective: To define the range of clinical conditions Canadian emergency pediatricians consider appropriate for management by physician assistants (PAs) and the degree of autonomy PAs should have in the pediatric emergency department (PED)., Methods: We conducted a cross-sectional, pan-Canadian survey using electronic questionnaire technology: the Active Campaign Survey tool. We targeted PED physicians using the Pediatric Emergency Research Canada (PERC) network database (N  =  297). Three outcome measures were assessed: demographic information, familiarity with PAs, and PA clinical roles in the PED. The level of PA involvement was assessed for 57 common nonemergent clinical conditions., Results: Of 297 physicians, 152 completed the survey, for a response rate of 51.2%. None of the 57 clinical categories achieved at least 85% agreement regarding PA management without direct physician involvement. Twenty-four clinical conditions had ≥ 15% agreement that any PA involvement would be inappropriate. For the remaining 33 clinical conditions, more than 85% of respondents felt that PA could appropriately manage but were divided between requiring direct and only indirect physician supervision. Respondents' selection of the number of conditions felt to be appropriate for PA involvement varied between the size of the emergency department (ED) in which they work (larger EDs 87.7-89.1% v. smaller EDs 74.2%) and familiarity with the clinical work of PAs in the ED (90.5-91.5% v. 82.2-84.7%)., Conclusion: This national survey of Canadian PED physicians suggests that they feel PAs could help care for a large number of nonemergent clinical cases coming to the PED, but these clinical encounters would have to be directly supervised by a physician.

Background: Patient safety is of great importance in the pediatric emergency department (PED). The combination of acutely and critically ill patients and high patient volumes creates a need for systems to support physicians in making accurate and timely diagnoses. Electronic patient tracking systems can potentially improve PED safety by reducing overcrowding and enhancing security., Objectives: To enhance our understanding of current electronic tracking technologies, how they are implemented in a clinical setting, and resulting effect on patient care outcomes including patient safety., Methods: Nine databases were searched. Two independent reviewers identified articles that contained reference to patient tracking technologies in pediatrics or emergency medicine. Quantitative studies were assessed independently for methodological strength by two reviewers using an external assessment tool., Results: Of 2292 initial articles, 22 were deemed relevant. Seventeen were qualitative, and the remaining five quantitative articles were assessed as being methodologically weak. Existing patient tracking systems in the ED included: infant monitoring/abduction prevention; barcode identification; radiofrequency identification (RFID)- or infrared (IR)-based patient tracking. Twenty articles supported the use of tracking technology to enhance patient safety or improve efficiency. One article failed to support the use of IR patient sensors due to study design flaws., Conclusions: Support exists for the use of barcode-, IR-, and RFID-based patient tracking systems to improve ED patient safety and efficiency. A lack of methodologically strong studies indicates a need for further evidence-based support for the implementation of patient tracking technology in a clinical or research setting., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: The objectives of this study were to outline the clinical conditions presenting to a Canadian pediatric emergency department (ED), survey the opinions of physician assistants (PAs) and emergency pediatricians to determine which conditions they consider could be managed by PAs, and to estimate the proportion of the total pediatric ED volume that PAs could potentially manage., Methods: We reviewed the 2007 British Columbia Children's Hospital database of ED visits to identify clinical presentation and chief complaint of all patients seen. International Classification of Diseases, 10th Revision codes were used to categorize the presenting complaint of each ED visit. Following categorization, the results were discussed by a focus group composed of pediatric emergency medicine-trained physicians and PAs, to review the list of chief complaints. We then surveyed via e-mailed questionnaire a group of emergency pediatricians (n = 17) and PAs (n = 5) to seek their opinion on the categories of clinical presentation appropriate for PA management., Results: Of 38,722 visits, 9.2% were triaged as "resuscitation" or "emergent." We sorted the remaining 35,077 ED visits into 57 clinical categories. More than 85% of respondents selected 30 clinical categories for PA management with physician supervision, representing 74% of the total ED volume. Of these, 3 were also deemed appropriate for PA management without direct physician supervision. There were statistically significant differences in mean length of stay, waiting time, and admission rates between the clinical conditions selected for PA involvement. However, the difference in waiting time was not clinically meaningful., Conclusions: A large proportion of pediatric ED visits are designated as semiurgent or nonurgent. Clinicians (ED physicians and PAs) thought that the majority of these ED visits could be managed by PAs.

Objectives: Fracture pain in the pediatric emergency department generally is treated with systemic analgesia using opioids. Fracture pain can alternatively be controlled with ultrasound (U/S)-guided nerve blocks for which only minimal training is available to pediatric emergency medicine physicians. This study evaluated the effects of a Web- and half-day simulation-based U/S course. Outcome measures were physician comfort level with and intention to use U/S-guided nerve blocks in clinical practice., Methods: We conducted a presurvey and postsurvey study targeting pediatric emergency medicine physicians. Participants completed a Web-based tutorial and a half-day simulation program. Participants completed survey questionnaires to document their comfort level and intention to use U/S-guided nerve blocks. Questionnaires were completed before, immediately after, and 1 month after course., Results: Eleven physicians participated in the study. The participants' comfort with and intention to use U/S-guided ulnar and femoral nerve blocks increased immediately after course, but neither increase was sustained 1 month after course. Immediately following the course, participants reported that the course addressed their learning needs (91%) and that they would consider advanced training (91%). One month after course, participants reported that they would partake in refresher courses (82%), particularly if offered once per year (64%)., Conclusions: This study suggests that Web- and simulation-based learning can increase comfort and intention to use U/S-guided nerve blocks and the need for follow-on training. Participants reported that their learning needs were met but that they would need annual refresher courses.

Objectives: Prediction of pediatric emergency department (PED) workload can allow for optimized allocation of resources to improve patient care and reduce physician burnout. A measure of PED workload is thus required, but to date no variable has been consistently used or could be validated against for this purpose. Billing codes, a variable assigned by physicians to reflect the complexity of medical decision making, have the potential to be a proxy measure of PED workload but must be assessed for reliability. In this study, we investigated how reliably billing codes are assigned by PED physicians, and factors that affect the inter-rater reliability of billing code assignment. Methods: A retrospective cross-sectional study was completed to determine the reliability of billing code assigned by physicians (n = 150) at a quaternary-level PED between January 2018 and December 2018. Clinical visit information was extracted from health records and presented to a billing auditor, who independently assigned a billing code–considered as the criterion standard. Inter-rater reliability was calculated to assess agreement between the physician-assigned versus billing auditor-assigned billing codes. Unadjusted and adjusted logistic regression models were used to assess the association between covariables of interest and inter-rater reliability. Results: Overall, we found substantial inter-rater reliability (AC2 0.72 [95% CI 0.64–0.8]) between the billing codes assigned by physicians compared to those assigned by the billing auditor. Adjusted logistic regression models controlling for Pediatric Canadian Triage and Acuity scores, disposition, and time of day suggest that clinical trainee involvement is significantly associated with increased inter-rater reliability. Conclusions: Our work identified that there is substantial agreement between PED physician and a billing auditor assigned billing codes, and thus are reliably assigned by PED physicians. This is a crucial step in validating billing codes as a potential proxy measure of pediatric emergency physician workload. [ABSTRACT FROM AUTHOR]

Objective: We evaluated the moderating effect of preinjury psychosocial function on postconcussion symptoms for children with mild traumatic brain injury (mTBI). Design, Setting, and Population: We conducted a prospective cohort study of children ages 8.0 to 16.9 years with mTBI (n = 633) or orthopedic injury (OI; n = 334), recruited from 5 pediatric emergency departments from September 2016 to December 2018. Main Measures: Participants completed baseline assessments within 48 hours of injury, and postconcussion symptoms assessments at 7 to 10 days, weekly to 3 months, and biweekly to 6 months post-injury. Preinjury psychosocial function was measured using parent ratings on the Pediatric Quality of Life Inventory (PedsQL) and the Strengths and Difficulties Questionnaire (SDQ), retrospectively evaluating their child's status prior to the injury. Parent and child ratings on the Health and Behavior Inventory (HBI) (cognitive and somatic subscales) and the Post-Concussion Symptom Interview (PCS-I) were used as measures of postconcussion symptoms. We fitted 6 longitudinal regression models, which included 747 to 764 participants, to evaluate potential interactions between preinjury psychosocial function and injury group as predictors of child- and parent-reported postconcussion symptoms. Results: Preinjury psychosocial function moderated group differences in postconcussion symptoms across the first 6 months post-injury. Higher emotional and conduct problems were significantly associated with more severe postconcussion symptoms among children with mTBI compared with OI. Wald's χ2 for interaction terms (injury group × SDQ subscales) ranged from 6.3 to 10.6 (P values <.001 to.043) across parent- and child-reported models. In contrast, larger group differences (mTBI > OI) in postconcussion symptoms were associated with milder hyperactivity (Wald's χ2: 15.3-43.0, all P <.001), milder peer problems (Wald's χ2: 11.51, P =.003), and higher social functioning (Wald's χ2: 12.435, P =.002). Conclusions: Preinjury psychosocial function moderates postconcussion symptoms in pediatric mTBI, highlighting the importance of assessing preinjury psychosocial function in children with mTBI. [ABSTRACT FROM AUTHOR]

Objectives To measure the association between psychosocial problems and persistent post-concussive symptoms (PCS) in youth who were seen in the emergency department with mild traumatic brain injury (mTBI) or orthopedic injury (OI). Methods From a larger prospective cohort study, Advancing Concussion Assessment in Pediatrics (A-CAP), 122 child–guardian pairs who presented to the emergency department with mTBI (N  = 70) or OI (N  = 52) were recruited for this cross-sectional sub-study. Each pair completed 2 measures assessing PCS burden at 2 weeks, 3 months, and 6 months post-injury. At one visit, pairs concurrently completed MyHEARTSMAP, a comprehensive, psychosocial self-assessment tool to evaluate 4 domains of mental wellness. Results When measured at the same visit, children who self-reported moderate or severe Psychiatry domain concerns concurrently experienced a greater burden of cognitive symptoms (β  = 5.49; 0.93–10.05) and higher overall PCS count (β  = 2.59; 0.70–4.48) after adjusting for covariables, including retrospective pre-injury symptoms and injury group. Additionally, reports indicating mild Function domain severity were associated with increased cognitive (β  = 3.34; 95% CI: 0.69–5.99) and somatic symptoms (β  = 6.79; 2.15–11.42) and total symptom count (β  = 1.29; 0.18–2.39). Conclusion Increasing severity in multiple domains of mental health is associated with more PCS in youth. While the differences in PCS between the mTBI and OI groups appeared somewhat larger for children with more mental health concerns, the interaction was not statistically significant; larger sample sizes are needed to evaluate the moderating effect of psychosocial difficulties on post-concussion symptoms. [ABSTRACT FROM AUTHOR]

Objective: To explore parental perceptions of psychosocial screening in the paediatric emergency department and identify post-screening barriers to accessing mental health care. Methods: We conducted a qualitative study during the 30-day follow-up period of a larger prospective cohort study. Eligible youth and their accompanying parent/guardian first completed psychosocial self/proxy-screening using the MyHEARTSMAP tool and then received a standardized clinical mental health assessment. If the MyHEARTSMAP assessment provided youth with mental health resources recommendations, their parents were invited to a follow-up session. Thirty days (±5 days) after their ED visit, parents participated in a virtual interview to reflect and share their attitudes, perceptions and thoughts around the screening and mental health care-seeking process. Results: Of the 171 participants who received resource recommendations during their ED visit, 124 parents (72.5%; 95% CI 65.2–79.1%) completed the follow-up interview. Most parents endorsed positive perceptions of the screening process, describing it as an 'eye-opening' process that 'sparked conversation'. Most participants (74.2%; 95% CI 65.6–81.6) agreed with the resource recommendations they received. In terms of resources-seeking, only 41 participants (33.1%; 95% CI 24.9–42.1) attempted to access recommended supports. Families generally felt identified concerns were mild and 'not serious enough' to warrant resource-seeking, though many expressed an intention to seek care if concerns escalated. Conclusion: Perceptions of psychosocial screening in the ED were favourable and encouraging among participating parents of youth screened positive for psychosocial issues. Despite positive attitudes, only a fraction of the families invited to follow-up attempted to access care. Mental health may be perceived as low priority for many families, signifying the need for improved education and awareness building on the importance of early intervention. [ABSTRACT FROM AUTHOR]

Background Mental health issues are increasingly prevalent across Canada, reflected in rising presentations to emergency departments. To effectively address the needs of children and youth seeking mental health-related care in the emergency department and to judiciously use scarce mental health-related resources, we need to better identify the specific areas of psychosocial needs and accessibility of associated services. Objective To describe the types and severity of paediatric mental health-related presentations evaluated at a quaternary paediatric emergency department, and to explore the accessibility of community mental health-related resources. Methods We conducted a retrospective cohort study of children and youth presenting to a quaternary paediatric emergency department who were assessed using HEARTSMAP, a validated mental health assessment and management tool. We reported the proportion who sought care for a psychiatric, social, or youth health-related mental health complaint. We contacted community mental health-related resources for their estimated wait times to determine accessibility. Results Of 1,530 paediatric emergency presentations, 98.8% of patients had psychiatric issues (40.1% were severe), 78.0% of patients had social issues (17.1% were severe), and 71.5% had youth health issues (18.1% were severe). We contacted 123 community mental health-related resources. Community youth health and social services were somewhat accessible, with 50.0% and 38.7%, respectively, able to intake youth within a week of referral. Community psychiatric programs were least accessible, with 59.3% having wait times greater than 1 month. Conclusions Many psychiatric concerns presenting in paediatric emergency departments have complex psychosocial challenges requiring non-psychiatric support. A need exists for improved accessibility to community psychiatric programs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Most pediatric ED visits are for nonemergent problems. Physician assistants are well trained to manage these patients; however, their effect on patient flow in a pediatric ED is unknown. Objectives: To compare the effect on key pediatric ED efficiency indicators of extending physician coverage versus adding PAs with equivalent incremental costs. Methods: We used discrete event simulation modeling to compare the effect of additional physician coverage versus adding PAs on wait time, length of stay (LOS), and patients leaving without being seen. Results: Simulation of extended physician coverage reduced wait times, LOS, and rates of leaving without being seen across acuity levels. Adding PAs reduced wait times and LOS for high-acuity visits, and slightly increased the LOS for low-acuity visits. Conclusions: With restricted autonomy, PAs mainly benefitted the high-acuity patients. Increasing the level of PA autonomy was critical in broadening the effect of PAs to all acuity levels. [ABSTRACT FROM AUTHOR]

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Abstract: Objective: To describe rate and determinants of influenza vaccination among Canadian youths. Methods: We conducted an analysis of cross-sectional data from the Canadian Community Health Survey (CCHS) cycle 3.1 collected by Statistics Canada in 2005. This is a population-based survey collecting information pertaining to the Canadian population health status, health care utilization and health determinants. The CCHS 3.1 included 12,170 respondents age 12–17 years old who answered questions pertaining to influenza vaccination. We used multivariate logistic regression to estimate the odds of having received the influenza vaccination in the last 12 months, adjusting for potential confounders. Results: Less than a quarter of Canadian youth reported receiving the influenza vaccination in the previous year. The most common reason for not getting the vaccination was “did not think it was necessary” (40.82%). Having chronic illness, and being an immigrant was significantly associated with a higher odds of receiving the influenza vaccination, while having an allergy and increasing frequency of alcohol drinking was associated with lower odds of receiving influenza vaccination. Smoking status acted as an effect modifier for many variables except for immigration status. Conclusions: Influenza vaccination rate in Canadian youths is low. Judgement values on its necessity are a major factor in the decision to receive influenza vaccination. Strategies to involve youths in influenza vaccination programs and campaigns will be essential to achieve better national coverage. [Copyright &y& Elsevier]

The COVID-19 pandemic arrived with significant hardship. The secondary impacts of the pandemic and our response with respect to pediatric mental health has been a subject of significant discussion in the lay public, media, and decision-maker groups. The initiatives to control SARS-CoV-2 have become politicized. A narrative emerged early that strategies to mitigate the spread of the virus were harming children’s mental health. Position statements from professional organizations in Canada have been used to support this claim. The aim of this commentary is to provide a reanalysis of some of the data and research methodology used to support these position statements. Some of the direct claims such as “online learning is harmful,” should be supported by a strong evidence base with significant consensus that speaks directly to causality. We find that the quality of the studies and the heterogeneity of the results does not support the strength of the unequivocal claims made by these position statements. In a sample of the current literature examining the issue, we find that outcomes range from improvements to deteriorations. Earlier studies relying on cross-sectional surveys typically have shown stronger negative effects than longitudinal cohort studies, which often have also shown groups of children experiencing no changes to measured mental health characteristics or groups that have experienced improvements. We argue it is imperative that policymakers use the highest quality evidence in making the best decisions. We as professionals must avoid discussing only one side of heterogeneous evidence. [ABSTRACT FROM AUTHOR]

Background: Evidence suggests emergency department (ED) overcrowding is associated with poor health outcomes. Children comprise 20-25% of general ED visits, yet few studies have examined the differential impact of ED overcrowding on pediatric and adult populations.Objective: The primary objective of this study was to compare flow measures, such as wait time to see a physician, length of stay (LOS), and rate of patients leaving without being seen by a physician (LWBS) between adults and children in British Columbia and Ontario, clustered by province, and then stratified by acuity level during the study period.Methods: We conducted a retrospective, repeated cross-sectional study using administrative data from all community EDs in Ontario and 10 EDs in the Vancouver Lower Mainland, British Columbia. Visits from January 1, 2008 and December 31, 2012 were included.Results: Visit volumes increased 13.9% per year in British Columbia and 2.2% per year in Ontario, with a more pronounced rise in adult visits. Both groups displayed a shift toward higher-acuity presentations. Adults spent more time in the ED compared to children (36 to 53 min longer), and were more likely to be admitted. Children consistently spent a greater portion of their visit awaiting assessment compared to adults.Conclusions: In the context of system incentives to reduce overcrowding, ED LOS and the LWBS rate did not significantly change for either children or adults, despite increased visit volume and acuity. Our findings suggest that measures to improve patient flow might have provided EDs with the means to meet increased demands on departmental resources. [ABSTRACT FROM AUTHOR]

Background: Return visits to the emergency department (RTED) contribute to overcrowding and may be a quality of care indicator. Previous studies focused on factors predicting returns to and from the same center. Little is known about RTEDs across a range of community and specialty hospitals within a large geographic area.Objective: We sought to measure the frequency of pediatric RTEDs and describe their directional pattern across centers in a large catchment area.Methods: We conducted a multicenter, retrospective cross-sectional study of pediatric emergency visits in the Vancouver lower mainland within 1 year. Visits were linked across study sites, including one pediatric quaternary care referral center and 17 sites ranging from large regional centers to smaller community emergency departments (EDs). Returns were defined as subsequent visits to any site with a compatible diagnosis within 7 days of an index visit.Results: Among a total of 139,278 index ED visits by children, 12,133 (8.7% [95% confidence interval 8.6-8.9%]) were associated with 14,645 return visits to an ED. Three quarters of all index visits occurred at a general ED center, of which 8.9% had at least one RTED and 22% of these returns occurred at the pediatric ED (PED). Among PED index visits, 8.2% had at least one RTED and 13.6% of these returned to a general center. Overall, 38.9% of all RTEDs occurred at the PED. Multivariate regression did not identify any statistically significant association between ED crowding measures and likelihood of RTEDs.Conclusions: Compared to single-center studies, this study linking hospitals within a large geographic area identified a higher proportion of RTEDs with a disproportionate burden on the PED. [ABSTRACT FROM AUTHOR]