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Background: Understanding the psychosocial status of children and adolescents during the COVID-19 pandemic is vital to the appropriate and adequate allocation of social supports and mental health resources. This study evaluates the burden of mental health concerns and the impact of demographic factors while tracking mental health service recommendations to inform community service needs. Methods: MyHEARTSMAP is a digital self-assessment mental health evaluation completed by children and their guardian throughout British Columbia between August 2020 to July 2021. Severity of mental health concerns was evaluated across psychiatric, social, functioning, and youth health domains. Proportional odds modelling evaluated the impact of demographic factors on severity. Recommendations for support services were provided based on the evaluation. Results: We recruited 541 families who completed 424 psychosocial assessments on individual children. Some degree of difficulty across the psychiatric, social, or functional domains was reported for more than half of children and adolescents. Older youth and those not attending any formal school or education program were more likely to report greater psychiatric difficulty. Girls experienced greater social concerns, and children attending full-time school at-home were more likely to identify difficulty within the youth health domain but were not more likely to have psychiatric difficulties. Considerations to access community mental health service were triggered in the majority (74%) of cases. Conclusions: Psychosocial concerns are highly prevalent amongst children and adolescents during the COVID-19 pandemic. Based on identified needs of this cohort, additional community health supports are required, particularly for higher risk groups. [ABSTRACT FROM AUTHOR]

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. [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]

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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]

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]

Objectives: To determine the incidence, risk, and timing of mortality (unnatural and natural causes) among youth seen in a pediatric emergency department (ED) for mental health concerns, compared with matched non-mental health ED controls., Methods: This was a retrospective cohort study conducted at a quaternary pediatric ED in British Columbia. All visits for a mental health related condition between July 1st, 2005, and June 30th, 2015, were matched on age, sex, triage acuity, socioeconomic status, and year of visit to a non-mental health control visit. Mortality outcomes were obtained from vital statistics data through December 31st, 2016 (cumulative follow-up 74,390 person-years)., Results: Among all cases in our study, including 6,210 youth seen for mental health concerns and 6,210 matched controls, a total of 13 died of suicide (7.5/100,000 person-years) and 33 died of suicide or indeterminate causes (44/100,000 person-years). All-cause mortality was significantly lower among mental health presentations (121.3/100,000 v. 214.5/100,000 person-years; hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.37-0.78). The median time from initial emergency visit to suicide was 5.2 years (interquartile range, 4.2-7.3). Among mental health related visits, risk of death by suicide or indeterminate cause was three-fold that of matched controls (HR, 3.05 95%CI, 1.37-6.77)., Conclusions: While youth seeking emergency mental health care are at increased risk of death by unnatural causes, their overall mortality risk is lower than non-mental health controls. The protracted duration from initial presentation to suicide highlights the need for long-term surveillance and preventative care for youth seen in the ED for all mental health concerns.

Background: Pediatric returns to the emergency department (RTED) vary between 3% and 13% of the total ED volume of visits. However, the incidence and contribution of scheduled RTED on pediatric emergency department (PED) utilization is less clear. Antimicrobial stewardship programs on inpatient wards have been shown to improve judicious use of outpatient parenteral antimicrobial therapy (OPAT) in upon discharge. The implementation of such programs in PEDs has yet to be reported. The objectives of this study are to quantify the burden of scheduled RTED for OPAT on PED utilization and to examine how frequently OPAT use are supported by published practice standards for 3 common pediatric infections-cellulitis, pneumonia, and urinary tract infections., Methods: We conducted a single-center retrospective cohort study of all visits made to the British Columbia Children's Hospital PED from May 1, 2012, to April 30, 2013. We identified scheduled RTEDs and characterized those associated with OPAT use with regard to their measures of PED utilization and clinical features., Results: Of 3904 RTED visits, 1310 (33.6%) were scheduled, of which 1029 were OPAT related. Among the latter, 749 RTEDs (69%) were for cellulitis, pneumonia, or urinary tract infections. The median length of stay for OPAT-related RTEDs was 2.0 hours. For 75 (24%) of 317 index visits and 213 (28%) of 749 subsequent RTEDs, oral antibiotic therapy would have been an appropriate option and OPAT could have been avoided., Conclusions: Our findings suggest that OPAT poses a sizable burden on PED utilization, with a proportion of them potentially preventable.

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.

Objective: The objective of this study was to explore the factors associated with parents' decisions to bring their children to the pediatric emergency department (PED) for nonemergent concerns., Methods: We conducted a cross-sectional survey at a tertiary-care, pediatric referral center emergency department. We surveyed caregivers of children triaged to low-acuity levels using the Pediatric Canadian Triage and Acuity Scale. We used descriptive statistics to report the proportion of patients who have a primary care physician, who attempted to contact any health care providers prior to coming to the PED, and other factors surrounding the decision to come to the PED., Results: We approached 340 families, of which 300 were enrolled (uptake rate, 88.2%). We found that 32% (95% confidence interval, 0.26-0.37) attempted to contact another health care provider prior to coming to the PED, and 59% (95% confidence interval, 0.48-0.69) of those respondents were specifically instructed to come to the PED. The top 3 reasons for coming to the British Columbia Children's Hospital PED were (1) that it specializes in children, (2) child has medical issues previously managed at the same hospital, and (3) closest location to patient., Conclusions: Despite the majority of patients having a primary care physician, less than half of them actually contacted these providers (or another health care provider) before presenting to the PED for their nonurgent illness or injury. Of these, nearly two thirds were specifically instructed to come to the PED by the health care provider in the community.

Objective: The objectives of this study were to determine (1) the association between body mass index (BMI) and acute injury and (2) the association between BMI and bone fracture in children., Methods: Children 5 to 17 years old were recruited in the emergency department at the British Columbia Children's Hospital. Cases included children treated for an injury, and control subjects were children without an injury in the past 12 months. Participants were administered a questionnaire to derive average activity level and demographic data. Weight and height measurements were taken to calculate BMI. Bivariate and multivariate logistic regressions were used to estimate the odds of injury occurrence by BMI category and the impact of covariates., Results: Logistical regression, after adjusting for age, sex, activity level, and income level, did not reveal an increased association between BMI and acute injury in overweight odds ratio (OR) = 0.90 (0.48-1.70) and obese OR = 1.18 (0.60-2.33) children. Secondary outcome analyses failed to show an increased association between BMI and fracture in overweight OR = 0.44 (0.12, 1.66) and obese OR = 1.02 (0.31, 3.32) children., Conclusions: This study did not find increasing BMI to be associated with increased acute injury or bone fracture in children.

Objective: To determine the willingness of Canadians to accept treatment from physician assistants (PAs)., Design: Respondents were asked to be surrogate patients or parents under 1 of 3 conditions selected at random. Two scenarios involved injury to themselves, with the third involving injury to their children. The wait time for a physician was assumed to be 4 hours, whereas to explore the sensitivity of patients' preferences for a range of times, PA wait times were 30 minutes, 1 hour, and 2 hours., Setting: Vancouver, BC., Participants: Two hundred twenty-nine mothers attending a hospital with their children., Main Outcome Measures: The main outcome measure was the proportion of individuals in each scenario who were willing to be treated by PAs for at least one of the time trade-off options offered. A secondary outcome was the proportion of individuals who changed their answers when the waiting time to see the PA varied., Results: Regardless of the scenarios, 99% of participants opted for PAs under the personal circumstances; 96% opted for PAs when the issue involved their children. The choice favouring the PA persisted, albeit at slightly lower proportions, as the difference in wait time between PAs and physicians decreased (85% and 67% for a difference in PA and physician wait time of 3 and 2 hours, respectively)., Conclusion: These findings suggest that British Columbians are willing to be treated by PAs under most circumstances, whether this includes themselves or their children. The high level of willingness to be treated by PAs demonstrates public confidence in PA care, and suggests that the use of PAs in Canadian emergency departments or clinics is a viable policy response to decreasing primary care capacity.

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.

Objective: To compare the incremental cost and effects (averted admission) of using a metered-dose inhaler (MDI) against wet nebulization to deliver bronchodilators for the treatment of mild to moderately severe asthma in pediatric emergency departments (EDs)., Methods: We measured the incremental cost-effectiveness from the perspective of the hospital, by creating a model using outcome characteristics from a Cochrane systematic review comparing the efficacy of using MDIs versus nebulizers for the delivery of albuterol to children presenting to the ED with asthma. Cost data were obtained from hospitals and regional authorities. We determined the incremental cost-effectiveness ratio and performed probabilistic sensitivity analyses using Monte Carlo simulations., Results: Using MDIs in the ED instead of wet nebulization may result in net savings of Can$154.95 per patient. Our model revealed that using MDIs in the ED is a dominant strategy, one that is more effective and less costly than wet nebulization. Probabilistic sensitivity analyses revealed that 98% of the 10 000 iterations resulted in a negative incremental cost-effectiveness ratio. Sensitivity analyses around the costs revealed that MDI would remain a dominant strategy (90% of 10 000 iterations) even if the net cost of delivering bronchodilators by MDI was Can$70 more expensive than that of nebulized bronchodilators., Conclusions: Use of MDIs with spacers in place of wet nebulizers to deliver albuterol to treat children with mild-to-moderate asthma exacerbations in the ED could yield significant cost savings for hospitals and, by extension, to both the health care system and families of children with asthma.

Objectives: Acute respiratory tract infections represent a significant burden on pediatric emergency departments (ED) and families. We hypothesized that early and rapid diagnosis of a viral infection alleviates the need for ancillary testing and antibiotic treatment., Study Design: We conducted a randomized, controlled trial of children 3 to 36 months of age with febrile acute respiratory tract infections at a pediatric ED. Two hundred four subjects were randomly assigned to receive rapid respiratory viral testing on admission or a routine ED admission protocol. Outcome measures were: mean length of visits, rate of ancillary tests, and antibiotic prescription in the ED. A follow-up call was made to all study subjects to inquire about further healthcare visits, ancillary testing, and antibiotic prescription after ED discharge., Results: We did not find a statistically significant difference in ED length of visits, rate of ancillary testing, or antibiotic prescription rate in the ED between the study groups. There was, however, a significant reduction in antibiotic prescription after ED discharge (in the group who had rapid viral testing RR = 0.36; 95% CI = 0.14, 0.95)., Conclusions: Rapid multi-viral testing in the ED did not significantly affect ED patient treatment but may reduce antibiotic prescription in the community after discharge from the ED, suggesting a novel strategy to alter community physician antibiotic prescription patterns.