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Objective To evaluate the clinical features of Canadian adolescents admitted to the intensive care unit (ICU) for medically serious self-harm. Methods 2700 Canadian paediatricians were surveyed monthly over two years (January 2017 to December 2018) through the Canadian Paediatric Surveillance Program to ascertain data from eligible cases. Results Ninety-three cases (73 female; age 15.2 ± 1.5) met the case definition. Four provinces reported the majority of cases: Quebec (n = 27), Ontario (n = 26), Alberta (n = 21), and British Columbia (n = 8). There were 10 deaths, 9 by hanging. Overdose and hanging were the most frequently reported methods of self-harm (74.2% and 19.4%, respectively). Overdose was more common in females (80.8% females vs. 50% males; χ2 = 7.8 (1), p = .005), whereas hanging was more common in males (35% males vs. 15.1% females, χ2 = 3.9 (1), p = .04). More females than males had a past psychiatric diagnosis (79% vs. 58%; χ2 = 4.1 (1), p = .06), a previous suicide attempt (55.9% vs. 29.4%, χ2 = 3.8 (1), p = .05), and prior use of mental health service (69.7% vs. 27.8%, χ2 = 10.4 (1), p = .001). Family conflict was the most commonly identified precipitating factor (43%) of self-harm. Conclusions Among Canadian adolescents admitted to the ICU with medically serious self-harm, females demonstrate a higher rate of suicide attempts and prior mental health care engagement, whereas males are more likely to die by suicide. These findings are consistent with data from other adolescent samples, as well as data from working-age and older adults. Therefore, a sex-specific approach to suicide prevention is warranted as part of a national suicide prevention strategy; family conflict may be a specific target for suicide prevention interventions among adolescents.

While quality improvement (QI) and clinical research embody two distinct scientific approaches, they have the same ultimate goal-to improve health and patient care outcomes. By leveraging their respective strengths there is a higher likelihood of achieving and sustaining health improvements. Our objective was to create recommendations to enhance the collaboration of the Canadian emergency medicine QI and clinical research communities.An expert panel of eight ED clinicians with diverse QI and clinical research expertise drafted a list of recommendations based on their professional expertise and a scoping review of the literature. These recommendations were refined through consultation with national stakeholders and reviewed at the 2020 CAEP Virtual Academic Symposium, where feedback was received through several virtual platforms.The final six recommendations include that all emergency medicine providers should: (1) understand the role and application of both clinical research and QI science; that academic emergency medicine physicians should: (2) contribute to both local adoption and broad dissemination of project findings, (3) leverage QI methodologies in research projects to improve knowledge translation, and (4) ensure that project outcomes prioritize patient care; and that academic leaders should: (5) enhance the infrastructure for oversight of research and QI projects, and (6) encourage collaboration between researchers and QI experts by ensuring that academic and operational infrastructures align and support both.Six recommendations are presented to help the Canadian emergency medicine community achieve greater collaboration between researchers and QI experts with the ultimate goal of improving patient care outcomes.RéSUMé: OBJECTIFS: Bien que l’amélioration de la qualité (AQ) et la recherche clinique représentent deux approches scientifiques distinctes, elles ont le même but ultime: améliorer la santé et les résultats des soins aux patients. En tirant profit de leurs atouts respectifs, les chances d’obtenir et de soutenir des améliorations de santé sont plus élevées. Notre objectif était de créer des recommandations pour renforcer la collaboration entre les communautés d'AQ et de recherche clinique en médecine d'urgence canadienne. MéTHODES: Un groupe d’experts de huit cliniciens des services d’urgence dotés d’une expertise diversifiée en matière d’AQ et de recherche clinique a rédigé une liste de recommandations basées sur leur expertise professionnelle et un examen de la revue de littérature. Ces recommandations ont été affinées en consultation avec les parties prenantes nationales et examinées lors du Symposium académique virtuel de ACMU 2020, où des commentaires ont été reçus via plusieurs plateformes virtuelles. RéSULTATS: Les six recommandations finales incluent que tous les prestataires des services de médecine d’urgence devraient: (1) comprendre le rôle et l’application de la recherche clinique et de la science de l’AQ; que les médecins universitaires en médecine d’urgence devraient: (2) contribuer à la fois à l’adoption locale et à la diffusion large des résultats de projets, (3) tirer parti des méthodologies d’AQ dans les projets de recherche afin d’améliorer l’application des connaissances, et (4) veiller à ce que les résultats de projet donnent la priorité aux soins aux patients; et que les dirigeants universitaires devraient: (5) améliorer l’infrastructure de surveillance des projets de recherche et d’AQ, et (6) encourager la collaboration entre les chercheurs et les experts en AQ en assurant que les infrastructures universitaires et opérationnelles les alignent et les soutiennent. CONCLUSION: Six recommandations sont présentées pour aider la communauté de la médecine d’urgence canadienne à parvenir à une plus grande collaboration entre les chercheurs et les experts en AQ dans le but ultime d’améliorer les résultats des soins aux patients.

Objectives Emergency department (ED) volumes have drawn attention to frequent users but less attention has been paid to children. This study examined sociodemographic and ED presentation characteristics of pediatric high-system ED users (HSUs) in 2 provinces in Canada. Methods Cohorts of HSUs were created from the National Ambulatory Care Reporting System in 2015/2016 for children with the top 10% of ED presentations. Controls were random samples of non-HSU patients. Factors were explored in multivariable logistic regression models. Results There were 151,497 HSUs (51.7% girls, average age, 6.4 years) and 591,545 controls (53.1% girls; average age, 7.4 years). High-system ED users were more likely to be younger (adjusted odds ratio [aOR], 0.89 per 5 years; 95% confidence interval [CI], 0.88-0.89), live in less populated areas (aOR, 1.85; 95% CI, 1.82-1.88), and from lowest income neighborhoods (aOR, 1.51; 95% CI, 1.48-1.54) than controls. High-system ED users had higher proportions of presentations for pediatric complex chronic (aOR, 1.25 per 0.25 increase; 95% CI, 1.21-1.29), respiratory (aOR, 1.14 per 0.25; 95% CI, 1.12-1.15), and mental health (aOR, 1.14 per 0.25; 95% CI, 1.13-1.16) conditions than controls. Conclusions Complex factors underlie pediatric health care utilization decisions. Findings identified conditions to target in interventions to improve health care access and utilization. Future work should engage children and families to design interventions.

IntroductionChildren and youth with mental health and addiction crises are a vulnerable patient group that often are brought to the hospital for emergency department care. We propose to evaluate the effect of a novel, acute care bundle that standardises a patient-centred approach to care.Methods and analysisTwo paediatric emergency departments in Alberta, Canada are involved in this prospective, pragmatic, 29-month interventional quasi-experimental study. The acute care bundle comprises three components, applied when appropriate: (1) assessing self-harm risk at triage using the Ask Suicide-Screening Questionnaire (ASQ) to standardise the questions administered, enabling risk stratification; (2) use of the HEADS-ED (Home, Education, Activities/peers, Drug/alcohol, Suicidality, Emotions and behaviour, Discharge Resources) to focus mental health evaluations for those who screen high risk on the ASQ; and (3) implementation of a Choice And Partnership Approach to enable shared decision making in care following the emergency department visit. The overarching goal is to deliver the right care at the right place and time for the patients. The study design involves a longitudinal collection of data 12 months before and after the introduction of the bundle and the use of quality improvement strategies such as Plan-Do-Study-Act cycles during a 5-month run-in period to test and implement changes. The primary study end-point is child/youth well-being 1 month after the emergency department visit. Secondary outcomes include family functioning, child/youth well-being at 3 and 6 months, satisfaction with emergency department care, and health system outcomes (hospital admissions, length of emergency department stays, emergency department revisits).Ethics and disseminationThe study is registered at www.ClinicalTrials.gov and has received ethics and operational approvals from study sites. The results of the study will be reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement. Results will be shared broadly with key policy and decision makers and disseminated in peer-reviewed academic journals and presentations at conferences.Trial registration numberNCT04292379.

IntroductionMild traumatic brain injury (mTBI) is highly prevalent, especially in children under 6 years. However, little research focuses on the consequences of mTBI early in development. The objective of the Kids’ Outcomes And Long-term Abilities (KOALA) study is to document the impact of early mTBI on children’s motor, cognitive, social and behavioural functioning, as well as on quality of life, stress, sleep and brain integrity.Methods and analysesKOALA is a prospective, multicentre, longitudinal cohort study of children aged 6 months to 6 years at the time of injury/recruitment. Children who sustain mTBI (n=150) or an orthopaedic injury (n=75) will be recruited from three paediatric emergency departments (PEDs), and compared with typically developing children (community controls, n=75). A comprehensive battery of prognostic and outcome measures will be collected in the PED, at 10 days, 1, 3 and 12 months postinjury. Biological measures, including measures of brain structure and function (magnetic resonance imaging, MRI), stress (hair cortisol), sleep (actigraphy) and genetics (saliva), will complement direct testing of function using developmental and neuropsychological measures and parent questionnaires. Group comparisons and predictive models will test the a priori hypotheses that, compared with children from the community or with orthopaedic injuries, children with mTBI will (1) display more postconcussive symptoms and exhibit poorer motor, cognitive, social and behavioural functioning; (2) show evidence of altered brain structure and function, poorer sleep and higher levels of stress hormones. A combination of child, injury, socioenvironmental and psychobiological factors are expected to predict behaviour and quality of life at 1, 3 and 12 months postinjury.Ethics and disseminationThe KOALA study is approved by the Sainte-Justine University Hospital, McGill University Health Centre and University of Calgary Conjoint Health Research Ethics Boards. Parents of participants will provide written consent. Dissemination will occur through peer-reviewed journals and an integrated knowledge translation plan.

Background Suicide is the second leading cause of death among Canadian adolescents. Youth who make near fatal suicide attempts, such as those requiring intensive care unit (ICU) level care, are the closest proxy to those that die by suicide; however, there is limited data on this group. Objectives To evaluate the minimum incidence rate and patterns of presentation of youth (under 18 years of age) admitted to the ICU for medically serious self-inflicted injury. Design/Methods From January 2017 to December 2018, over 2,700 paediatricians/subspecialist members of the Canadian Paediatric Surveillance Program were electronically surveyed on a monthly basis regarding cases of medically serious self-harm. Participants completed a detailed questionnaire about the reported case and descriptive statistics were used for analyses. Results Ninety-four cases (71 female; mean age 15.2 years) of confirmed (n=87) and suspected/probable (n=7) medically serious self-harm were reported. The majority (87%) of cases were reported from 4 out of 13 provinces and territories in Canada (Alberta, British Columbia, Ontario, Quebec). There were 11 deaths by suicide (M>F; p Conclusion These Canadian findings are consistent with international epidemiologic data that observe a gender paradox of higher rates of suicide attempts in females and greater mental health care engagement but increased suicide mortality in males with decreased involvement with mental health care. This study suggests that family conflict is a potential target for suicide prevention interventions among youth. Future research focusing on gender-specificity in risk factor identification and effectiveness of primary prevention interventions among youth is warranted.

ObjectiveDespite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies show that patients still receive low-value care (e.g., respiratory viral testing, salbutamol, chest radiography). Our objective was to decrease low-value care by delivering individual physician reports, in addition to group-facilitated feedback sessions to pediatric emergency physicians.MethodsOur cohort included 3,883 patients ≤ 12 months old who presented to pediatric emergency departments in Calgary, Alberta, with a diagnosis of bronchiolitis from April 1, 2013, to April 30, 2018. Using administrative data, we captured baseline characteristics and therapeutic interventions. Consenting pediatric emergency physicians received two audit and feedback reports, which included their individual data and peer comparators. A multidisciplinary group-facilitated feedback session presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention and was analysed using statistical process control charts.ResultsSeventy-eight percent of emergency physicians consented to receive their audit and feedback reports. Patient characteristics were similar in the baseline and intervention period. Following the baseline physician reports and the group feedback session, low-value care decreased from 42.6% to 27.1% (absolute difference: −15.5%; 95% CI: −19.8% to −11.2%) and 78.9% to 64.4% (absolute difference: −14.5%; 95% CI: −21.9% to −7.2%) in patients who were not admitted and admitted, respectively. Balancing measures, such as intensive care unit admission and emergency department revisit, were unchanged.ConclusionThe combination of audit and feedback and a group-facilitated feedback session reduced low-value care for patients with bronchiolitis.

IntroductionMusculoskeletal (MSK) injuries are a frequent cause for emergency department (ED) visits in children. MSK injuries are associated with moderate-to-severe pain in most children, yet recent research confirms that the management of children’s pain in the ED remains inadequate. Clinicians are seeking better oral analgesic options for MSK injury pain with demonstrated efficacy and an excellent safety profile. This study aims to determine the efficacy and safety of adding oral acetaminophen or oral hydromorphone to oral ibuprofen and interpret this information within the context of parent/caregiver preference.Methods and analysisUsing a novel preference-informed complementary trial design, two simultaneous trials are being conducted. Parents/caregivers of children presenting to the ED with acute limb injury will be approached and they will decide which trial they wish to participate in: an opioid-inclusive trial or a non-opioid trial. Both trials will follow randomised, double-blind, placebo-controlled, superiority-trial methodology and will enrol a minimum of 536 children across six Canadian paediatric EDs. Children will be eligible if they are 6 to 17 years of age and if they present to the ED with an acute limb injury and a self-reported verbal Numerical Rating Scale pain score ≥5. The primary objective is to determine the effectiveness of oral ibuprofen+oral hydromorphone versus oral ibuprofen+oral acetaminophen versus oral ibuprofen alone. Recruitment was launched in April 2019.Ethics and disseminationThis study has been approved by the Health Research Ethics Board (University of Alberta), and by appropriate ethics boards at all recruiting centres. Informed consent will be obtained from parents/guardians of all participants, in conjunction with assent from the participants themselves. Study data will be submitted for publication regardless of results. This study is funded through a Canadian Institutes of Health Research grant.Trial registration numberNCT03767933, first registered on 07 December 2018.

Antipsychotic medication use has steadily increased in Canada, with an expansion in the profile of users and the diagnoses for which they are used. The use of antipsychotics is associated with a number of adverse effects for which routine monitoring is recommended. The objectives of this study were to determine the most common diagnoses associated with antipsychotic use in children in Alberta, Canada and the proportion who receive recommended laboratory tests for adverse effects. Data on dispensed antipsychotics, diagnoses, prescribers, and laboratory testing were obtained from provincial data sources. To assess the frequency of metabolic and hormonal laboratory baseline and/or follow-up testing, the sample was divided into an antipsychotic-naive cohort and an antipsychotic non-naive cohort. In 2014, 6916 children were dispensed at least one second- or third-generation antipsychotic. The most frequently dispensed antipsychotics were risperidone (3908 children), quetiapine (2140 children), and aripiprazole (1302 children). The majority of children prescribed risperidone were diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) or conduct disorder. Quetiapine was mainly prescribed for neurotic disorder or depression, while aripiprazole was prescribed most frequently for conduct disorder or neurotic disorders. Among antipsychotic-naive patients, 17% had at least one laboratory test done at baseline, and 35% had at least one laboratory test done at follow-up. In the non-naive patients, 42% had at least one follow-up laboratory test. Lipid and glucose testing were done in less than 5% of the naive cohort at baseline, and in less than 15% at follow-up. In the non-naive cohort, less than 22% received lipid or glucose testing during the year 2014. The majority of antipsychotic use in children in Alberta is off-label and associated with disruptive behavior disorders, depression, and anxiety disorders. The vast majority of children prescribed antipsychotic medications do not undergo recommended laboratory tests.

Background/objectives In 2013, the TRAPPED-1 survey reported inconsistent availability of pain and distress management strategies across all 15 Canadian paediatric emergency department (PEDs). The objective of the TRAPPED-2 study was to utilize a procedural pain quality improvement collaborative (QIC) and evaluate the number of newly introduced pain and distress-reducing strategies in Canadian PEDs over a 2-year period. Methods A QIC was created to increase implementation of new strategies, through collaborative information sharing among PEDs. In 2015, 11 of the 15 Canadian PEDs participated in the TRAPPED QIC. At the end of the year, the TRAPPED-2 survey was electronically sent to a representative member at each of the 15 PEDs. The successful introduction of the chosen strategies by the QIC was assessed as well as the addition of new strategies per site. The number of new strategies introduced in the participating and nonparticipating QIC sites were described. Results All 15 PEDs (100%) completed the TRAPPED-2 survey. Overall, 10/11 of QIC-participating sites implemented the strategy they had initially identified. All 15 Canadian PEDs implemented some new strategies during the study period; participants in the QIC reported a mean of 5.2 (1-11) new strategies compared to 2.5 (1-4) in the nonactively participating sites. Conclusion While all PEDs introduced new strategies during the study, QIC-participating sites successfully introduced the majority of their previously identified new strategies in a short time period. Sharing deadlines and information between centres may have contributed to this success.

The topics of quality improvement (QI) and patient safety have become important themes in health care in recent years, particularly in the emergency department setting, which is a frequent point of contact with the health care system for patients. In the first of three articles in this series meant as a QI primer for emergency medicine clinicians, we introduced the strategic planning required to develop an effective QI project using a fictional case study as an example. In this second article we continue with our example of improving time to antibiotics for patients with sepsis, and introduce the Model for Improvement. We will review what makes a good aim statement, the various categories of measures that can be tracked during a QI project, and the relative merits and challenges of potential change concepts and ideas. We will also present the Model for Improvement’s rapid-cycle change methodology, the Plan-Do-Study-Act (PDSA) cycle. The final article in this series will focus on the evaluation and sustainability of QI projects.

Children are particularly vulnerable to patient safety concerns due to pediatric-specific and general health care challenges. This scoping review identifies and describes the vulnerabilities of those aged 0 to 18 years to iatrogenic harm in various health care settings. Six databases were searched from 1991 to 2012. Primary studies were categorized using predetermined groupings. Categories were tallied and descriptive statistics were employed. A total of 388 primary studies exploring interventions that improved patient safety, deficiencies, or errors leading to safety concerns were included. The most common issues were medication (189 studies, 48.7%) and general medical (81 studies, 20.9%) errors. Sixty studies (15.5%) evaluated or described patient safety interventions, 206 studies (53.1%) addressed health care systems and technologies, 17 studies (4.4%) addressed caregiver perspectives and 20 studies (5.2%) discussed analytic models for patient safety. Further work is needed to ensure consistency of definitions in patient safety research to facilitate comparison and collation of results.

Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration.An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback.Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program.A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.L'amélioration de la qualité et la sécurité des patients (AQSP) joue un rôle important dans la correction des lacunes observées dans la prestation optimale de soins. Toutefois, les équipes de soins au service des urgences (SU) disposent de peu de documentation sur la conception de leurs propres programmes d'AQSP. L’étude avait donc pour objectif l’élaboration de recommandations conçues à l'intention des chefs de file, nouveaux ou confirmés, au SU, et présentées comme une voie à emprunter pour améliorer les soins aux patients, par l'application d'activités programmatiques d'AQSP, tout d'abord au sein du service, puis entre services, grâce à la collaboration.Un groupe d'experts composé de 10 cliniciens en médecine d'urgence, ayant des compétences particulières en AQSP et en pouvoir d'influence, a été mis sur pied. Un examen de cadrage a été entrepris à la recherche de publications sur l’établissement de programmes d'AQSP et de cadres de travail s'y rapportant, en soins de santé. Des consultations ont été menées avec les parties intéressées parmi les chefs de file en soins de santé au Canada, et le groupe d'experts a rédigé une version préliminaire de recommandations fondées sur l'ensemble de l'information recueillie. Celles-ci ont été examinées et améliorées durant le Symposium sur les affaires universitaires 2018 de l'ACMU, à Calgary, à la suite de rétroactions communiquées en personne ou par voie électronique.Les recommandations portaient sur : l’éveil d'un sentiment d'urgence à l’égard de l'amélioration; la mobilisation d'intervenants et de chefs de file compétents; la mise sur pied d'un comité local structuré d'AQSP; l'obtention de financement et de ressources; la disponibilité de données locales pour orienter le travail; le soutien de la formation des membres d’équipe en AQSP; la promotion de la collaboration entre professions, entre services et avec les patients; l'utilisation d'un cadre de travail d'AQSP déjà établi afin d'orienter le travail; l’élaboration d'un système de récompenses et de structures incitatives; la possibilité d'entreprendre, au début, des initiatives à petite échelle, soit des projets plutôt que des programmes.Les dix recommandations ont été présentées à titre de principes directeurs en vue de l’élaboration d'activités d'AQSP et de leur mise en œuvre durable dans les SU, au Canada et ailleurs dans le monde. Les chefs de file dans les SU sont invités à appliquer ces recommandations dans le but d'améliorer les soins aux patients.

ObjectiveAdverse events (AEs) associated with short-term corticosteroid use for respiratory conditions in young children.DesignSystematic review of primary studies.Data sourcesMedline, Cochrane CENTRAL, Embase and regulatory agencies were searched September 2014; search was updated in 2017.Eligibility criteriaChildren Data extraction and synthesisOne reviewer extracted with another reviewer verifying data. Study selection and methodological quality (McHarm scale) involved duplicate independent reviews. We extracted AEs reported by study authors and used a categorisation model by organ systems. Meta-analyses used Peto ORs (pORs) and DerSimonian Laird inverse variance method utilising Mantel-Haenszel Q statistic, with 95% CI. Subgroup analyses were conducted for respiratory condition and dose.ResultsEighty-five studies (11 505 children) were included; 68 were randomised trials. Methodological quality was poor overall due to lack of assessment and inadequate reporting of AEs. Meta-analysis (six studies; n=1373) found fewer cases of vomiting comparing oral dexamethasone with prednisone (pOR 0.29, 95% CI 0.17 to 0.48; I2=0%). The mean difference in change-from-baseline height after one year between inhaled corticosteroid and placebo was 0.10 cm (two studies, n=268; 95% CI −0.47 to 0.67). Results from five studies with heterogeneous interventions, comparators and measurements were not pooled; one study found a smaller mean change in height z-score with recurrent high-dose inhaled fluticasone over one year. No significant differences were found comparing systemic or inhaled corticosteroid with placebo, or between corticosteroids, for other AEs; CIs around estimates were often wide, due to small samples and few events.ConclusionsEvidence suggests that short-term high-dose inhaled or systemic corticosteroids use is not associated with an increase in AEs across organ systems. Uncertainties remain, particularly for recurrent use and growth outcomes, due to low study quality, poor reporting and imprecision.

BackgroundUnderstanding adverse events among children treated in the emergency department (ED) offers an opportunity to improve patient safety by providing evidence of where to focus efforts in a resource-restricted environment.ObjectiveTo estimate the risk of adverse events, their type, preventability and severity, for children seen in a paediatric ED.MethodsThis prospective cohort study examined outcomes of patients presenting to a paediatric ED over a 1-year period. The primary outcome was the proportion of patients with an adverse event (harm to patient related to healthcare received) related to ED care within 3 weeks of their visit. We conducted structured telephone interviews with all patients and families over a 3-week period following their visit to identify flagged outcomes (such as repeat ED visits, worsening symptoms) and screened admitted patients’ health records with a validated trigger tool. For patients with flagged outcomes or triggers, three ED physicians independently determined whether an adverse event occurred.ResultsOf 1567 eligible patients, 1367 (87.2%) were enrolled and 1319 (96.5%) reached in follow-up. Median patient age was 4.34 years (IQR 1.5 to 10.57 years) and most (n=1281; 93.7%) were discharged. Among those with follow-up, 33 (2.5%, 95% CI 1.8% to 3.5%) suffered an adverse event related to ED care. None experienced more than one event. Twenty-nine adverse events (87.9%, 95% CI 72.7% to 95.2%) were deemed preventable. The most common types of adverse events (not mutually exclusive) were management issues (51.5%), diagnostic issues (45.5%) and suboptimal follow-up (15.2%).ConclusionOne in 40 children suffered adverse events related to ED care. A high proportion of events were preventable. Management and diagnostic issues warrant further study.

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.

Objectives: Advanced nursing directives (ANDs) empower nursing staff to provide advanced levels of care before physician assessment. The objectives of this study were (1) to determine whether an AND for right lower quadrant (RLQ) pain could identify children who required any further investigation to diagnose appendicitis and (2) to determine whether children meeting AND criteria had better emergency department (ED) flow metrics compared with those who did not meet the criteria. Methods: Health records of children aged 3 to 17 years presenting to the ED with abdominal pain who were managed using the departmental AND for RLQ pain were reviewed. Primary outcomes included (1) the proportion of patients requiring further investigation to diagnose appendicitis and (2) the time interval from triage to blood draw. Secondary outcomes included additional ED flow metrics, perforation rate, and negative appendectomy rate. Results: An AND was completed for 210 children. Those who met the AND criteria were more likely to undergo further investigation to rule out appendicitis than those who did not meet the criteria (92/137 [67.2%] vs 32/73 [43.8%]; odds ratio [OR], 2.62; 95% confidence interval [CI], 1.40–4.90). Time to blood draw was significantly lower for those children meeting the AND criteria (74 vs 162 minutes, P < 0.001) as was time to hospital admission (271 vs 395 minutes, P = 0.008) and appendectomy (498 vs 602 minutes, P = 0.015). The negative appendectomy rate was 8.6% (5/58) for children meeting the AND criteria and 9.1% (2/22) for those not meeting the criteria (OR, 0.94; 95% CI, 0.14–10.67); the perforation rate was 29.3% (17/58) and 4.5% (1/22), respectively (OR, 8.17; 95% CI, 1.17–380.86). Conclusions: Children presenting to the ED with RLQ pain who meet the AND criteria are more likely to require further investigation to rule out appendicitis and have better department flow metrics than those who do not meet the criteria. Our results provide further evidence of the utility of ANDs in the ED.

Background: Despite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies suggest that many of these patients receive low-value interventions. Providing clinicians with their practice reports and peer comparator data or an achievable benchmark of care (audit and feedback) has been shown to be an effective strategy to improve adherence to guidelines. Aim Statement: To decrease low-value care (use of any or all of chest radiographs, viral testing and salbutamol) in infants with bronchiolitis by delivering individual physician reports in addition to Group Facilitated Feedback Sessions (GFFS) to pediatric emergency physicians (PEPs). Measures & Design: Our cohort included 3,883 patients ≤12 months old that presented to two emergency departments with a diagnosis of bronchiolitis from April 1, 2013 to April 30, 2018. Using administrative data we captured baseline characteristics and interventions. Consenting PEPs received two audit and feedback (A&F) reports which included their individual and peer comparator data. Two multi-disciplinary GFFS (including inpatient pediatricians, nurse, learners and respiratory therapists) presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention, and was analyzed using statistical process control charts. Process measures (consent to obtain report, attendance and evaluations from the feedback session) and balancing measures were also captured. Evaluation/Results: 78% of PEPs consented to receive their A&F reports. Patient baseline characteristics were similar in the baseline (n = 3109) and intervention period (n = 774). Following the baseline physician reports and the GFFS, low-value care decreased from 42.6% to 27.1% (absolute difference: -15.5%; 95% confidence interval (CI): -19.8% to -11.2%) and 78.9% to 64.4% (absolute difference: -14.5%; 95% CI: -21.9% to -7.2%) in patients who were not admitted and admitted, respectively. Balancing measures such as ICU admission (absolute difference: -0.6%; 95%CI: -5.7% to 4.4%) and ED revisit within 72 hours (absolute difference: -0.1%; 95% CI: -3.1% to 3.0% non-admitted patients, 1.0%; 95% CI: -1.2% to 3.2% admitted patients) were unchanged. Discussion/Impact: The combination of audit and feedback and a GFFS significantly reduced low-value care for pediatric patients with bronchiolitis by PEP's.

Background: Pediatric pain is often under-treated in emergency departments (EDs), causing short and long-term harm. In Alberta EDs, children's pain outcomes were unknown. A recent quality improvement collaborative (QIC) led by our team improved children's pain care in 4 urban EDs. We then spread to all EDs in Alberta using the Institute for Healthcare Improvement Framework for Going to Full Scale. Aim Statement: To increase the proportion of children Measures & Design: All 97 EDs in Alberta that treat children were invited. Each was asked to form a project team, attend webinars, develop key driver diagrams and perform PDSA tests of change. Sites were given a monthly list of randomly selected charts for audit and entered data in REDCap for upload to a provincial run chart dashboard. Baseline performance measurement informed aims. Measures included proportion of children Evaluation/Results: 36 sites (37%) participated, including rural and urban sites from all regions. 8417 visits were audited. 23/36 sites completed audits before and after tests of change and were analyzed. Special cause occurred for all aims. The proportion receiving topical anesthetic increased from 11% to 30% (ITS p Discussion/Impact: A pragmatic approach encouraging locally led change was well-received and key to success. The QIC method shows promise for improving outcomes in diverse EDs across large geographic areas. Next steps include further spread and sustainability measurement.

OBJECTIVES This study aimed to elicit pediatric emergency physician's treatment choices for preschool-aged children with wheeze, determine the characteristics of the presenting child that influence treatment choices, and determine whether there is clinical equipoise by eliciting physician willingness to enroll these children in a placebo-controlled trial of corticosteroids. METHODS Discrete choice experiments varying the characteristics of the presenting child were designed to elicit Canadian emergency physician's treatment choices, both in the emergency department (ED) and at discharge, for young children presenting with wheeze and their willingness to enroll in a randomized controlled trial (RCT). RESULTS Most physicians chose to treat children with albuterol both in the ED and at discharge for all clinical scenarios. The proportion of physicians who chose to treat children with oral corticosteroids both in the ED and at discharge varied widely (from 12% to 81%) across all scenarios. Physician preference whether preschool children with wheeze should be treated with corticosteroids varied depending on the child's age, history of atopy, and previous and continuous wheeze. Between 73% and 86% of physicians were willing to enroll these children in an RCT indicating clinical equipoise. CONCLUSIONS Physician treatment choices varied widely indicating clinical equipoise as to the effectiveness of corticosteroids in this population of patients. Management choices with respect to albuterol and corticosteroids were not consistent with published national and international guidelines. In line with this finding, physician's considerable willingness to enroll these children in an RCT may suggest that they are seeking guidance on how to manage these patients.

Background. We sought to develop diagnostic test guidance definitions for pediatric enteric infections to facilitate the interpretation of positive test results in the era of multianalyte molecular diagnostic test platforms.Methods. We employed a systematic, two-phase, modified Delphi consensus process consisting of three web-based surveys and an expert panel face-to-face meeting. In phase 1, we surveyed an advisory panel of North American experts to select pathogens requiring diagnostic test guidance definition development. In phase 2, we convened a 14-member expert panel to develop, refine, and select the final definitions through two web-based questionnaires interspersed with a face-to-face meeting. Both questionnaires asked panelists to rate the degree to which they agreed that if the definition is met the pathogen is likely to be causative of clinical illness.Results. The advisory panel survey identified 19 pathogens requiring definitions. In the expert panel premeeting survey, 13 of the 19 definitions evaluated were rated as being highly likely (“agree” or “strongly agree”) to be responsible for acute gastroenteritis symptoms by ≥67% of respondent panel members. The definitions for the remaining six pathogens (Aeromonas, Clostridium difficile, Edwardsiella,nonenteric adenovirus, astrovirus, andEntamoeba histolytica) were indeterminate. After the expert panel meeting, only two of the modified definitions,C. difficileandE. histolytica/dispar, failed to achieve thea priorispecified threshold of ≥67% agreement.Conclusions.We developed diagnostic test guidance definitions to assist healthcare providers for 17 enteric pathogens. We identified two pathogens that require further research and definition development.

ObjectivesLumbar punctures (LPs) are painful for children, and analgesia is recommended by academic societies. However, less than one-third of pediatric emergency physicians (EPs) adhere to recommendations. We assessed the willingness to provide analgesia among pediatric and general EPs and explored patient and provider-specific barriers.MethodsWe surveyed physicians in the Pediatric Emergency Research Canada (PERC) or Canadian Association of Emergency Physicians (CAEP) databases from May 1 to August 1, 2016, regarding hypothetical scenarios for a 3-week-old infant, a 3-year-old child, and a 16-year-old child requiring an LP. The primary outcome was the willingness to provide analgesia. Secondary outcomes included the type of analgesia, reasons for withholding analgesia, and their perceived competence performing LPs.ResultsFor a 3-week old infant, 123/144 (85.4%) pediatric EPs and 231/262 (88.2%) general EPs reported a willingness to provide analgesia. In contrast, the willingness to provide analgesia was almost universal for a 16-year-old (144/144 [100%] of pediatric EPs and 261/262 [99.6%] of general EPs) and a 3-year-old (142/144 [98.6%] of pediatric EPs and 256/262 [97.7%] of general EPs). For an infant, the most common barrier cited by pediatric EPs was the perception that it produced additional discomfort (13/21, 61.9%). The same reason was cited by general EPs (12/31, 38.7%), along with unfamiliarity surrounding analgesic options (13/31, 41.9%).ConclusionCompared to a preschool child and adolescent, the willingness to provide analgesia for an LP in a young infant is suboptimal among pediatric and general EPs. Misconceptions and the lack of awareness of analgesic options should be targets for practice-changing strategies.

Background A growing body of literature supports patient and public involvement in the design, prioritization, and dissemination of research and evidence-based medicine. The objectives of this project were to engage patients and families in developing a prioritized list of research topics for pediatric emergency medicine (PEM) and to compare results with prior research prioritization initiatives in the emergency department (ED) setting. Methods We utilized a systematic process to combine administrative data on frequency of patient presentations to the ED with multiple stakeholder input including an initial stakeholder survey followed by a modified Delphi consensus methodology consisting of two Web-based surveys and a face-to-face meeting. Results The prioritization process resulted in a ranked list of 15 research priorities. The top five priorities were mental health presentations, pain and sedation, practice tools, quality of care delivery, and resource utilization. Mental health, pain and sedation, clinical prediction rules, respiratory illnesses/wheeze, patient safety/medication error, and sepsis were identified as shared priorities with prior initiatives. Topics identified in our process that were not identified in prior work included resource utilization, ED communication, antibiotic stewardship, and patient/family adherence with recommendations. Conclusions This work identifies key priorities for research in PEM. Comparing our results with prior initiatives in the ED setting identified shared research priorities and opportunities for collaboration among PEM research networks. This work in particular makes an important contribution to the existing literature by including the patient/family perspective missing from prior work.

Objectives The suboptimal provision of analgesia to children in the emergency department (ED) is well-described. A yet unexplored barrier is caregiver or child refusal of analgesia. We sought to evaluate the frequency of caregiver/child acceptance of analgesia offered in the ED. Methods We conducted a two-centre cross-sectional study of 743 caregivers of children 4–17 years presenting to the pediatric ED with an acutely painful condition using a survey and medical record review. The primary outcome was the proportion of children/caregiver pairs who accepted analgesia in the ED. Results The median (IQR) age of children was 11 (7) years, and 339/743 (45.6%) were female. The overall survey response rate was 73% (743/1018). In the 24 hours preceding ED arrival, the median (IQR) maximal pain score rated by children and caregivers was 8/10 (4) and 5/10 (2), respectively, and 30.4% (226/743) of caregivers offered analgesia. In the ED, children reported a median (IQR) pain score of 8/10 (2) and 54.9% (408/743) were offered analgesia. When offered in the ED, analgesia was accepted by 91% (373/408). Overall, 55.7% (414/743) of children received some form of analgesia. Conclusions Most caregivers/children accept analgesia when offered by ED personnel, suggesting refusal is not a major barrier to optimal management of children’s pain and highlighting the importance of ED personnel in encouraging adequate analgesia. A large proportion of children in pain are not offered analgesia by caregivers or ED personnel. Educational strategies for recognizing and treating pain should be directed at children, caregivers, and ED personnel.

Purpose: Recent physician surveys show high self-reported rates of offering analgesia to children in the emergency department (ED). However, institutional audits of actual practice suggest sub-optimal analgesic administration persists. Reasons may include caregiver or patient refusal. Our objectives were to determine the proportions of children who were offered analgesia at home and children/caregivers who accepted analgesia in the ED. Methods: We conducted a multi-center prospective cohort study involving a caregiver survey and medical record review. We included children aged 4-17 years presenting to the ED with an acutely painful condition …

Objectives Despite the substantial body of literature on emergency department (ED) crowding, to the best of our knowledge, there is no agreement on the measure or measures that should be used to quantify crowding. The objective of this systematic review was to identify existing measures of ED crowding that have been linked to quality of care as defined by the Institute of Medicine (IOM) quality domains (safe, effective, patient-centered, efficient, timely, and equitable). Methods Six major bibliographic databases were searched from January 1980 to January 2012, and hand searches were conducted of relevant journals and conference proceedings. Observational studies (cross-sectional, cohort, and case-control), quality improvement studies, quasi-experimental (e.g., before/after) studies, and randomized controlled trials were considered for inclusion. Studies that did not provide measures of ED crowding were excluded. Studies that did not provide quantitative data on the link between crowding measures and quality of care were also excluded. Two independent reviewers assessed study eligibility, completed data extraction, and assessed study quality using the Newcastle-Ottawa Quality Assessment Scale (NOS) for observational studies and a modified version of the NOS for cross-sectional studies. Results The search identified 7,413 articles. Thirty-two articles were included in the review: six cross-sectional, one case-control, 23 cohort, and two retrospective reviews of performance improvement data. Methodologic quality was moderate, with weaknesses in the reporting of study design and methodology. Overall, 15 of the crowding measures studied had quantifiable links to quality of care. The three measures most frequently linked to quality of care were the number of patients in the waiting room, ED occupancy (percentage of overall ED beds filled), and the number of admitted patients in the ED awaiting inpatient beds. None of the articles provided data on the link between crowding measures and the IOM domains reflecting equitable and efficient care. Conclusions The results of this review provide data on the association between ED crowding measures and quality of care. Three simple crowding measures have been linked to quality of care in multiple publications.

Objectives The aim of this study was to describe patient-reported pain outcomes at various stages of an emergency department (ED) visit for pediatric limb injury. Methods This prospective cohort consisted of 905 patients aged 4 to 17 years with acute limb injury and a minimum initial pain score of 4/10. Patients reported pain scores and treatments offered and received at each stage of their ED visit. Multiple logistic regression was used to identify predictors for severe pain on initial assessment and moderate or severe pain at ED discharge. Results The initial median pain score was 6/10 (interquartile range, 4-6) and decreased at discharge to 4/10 (interquartile range, 2-6). Stages of the ED visit where the highest proportion of patients reported severe pain (score, ≥8 of 10) were fracture reduction (26.0% [19/73]; 95% confidence interval [CI], 17.1%-37.5%), intravenous insertion (24.4% [11/45]; 95% CI, 13.8%-39.6%), and x-ray (23.7% [158/668]; 95% CI, 20.6%-27.0%). Predictors of severe pain at initial assessment included younger age (odds ratio [OR], 0.92; 95% CI, 0.87-0.97), female sex (OR, 0.58; 95% CI, 0.40-0.84), and presence of fracture (OR, 1.58; 95% CI, 1.07-2.33) whereas, at discharge, older age (OR, 1.14; 95% CI, 1.06-1.23) predicted moderate/severe pain (score, ≥4 of 10). Conclusions These results on the location and predictors of severe pain during an ED visit for limb injury can be used to target interventions to improve pain management and patient outcomes.

Emergency medicine (EM) providers work in a fast-paced and often hectic environment that has a high risk for patient safety incidents and gaps in the quality of care. These challenges have resulted in opportunities for frontline EM providers to play a role in quality improvement (QI) projects. QI has developed into a mature field with methodologies that can dramatically improve the odds of having a successful project with a sustainable impact. However, this expertise is not yet commonly taught during professional training. In this first of three articles meant as a QI primer for EM clinicians, we will introduce QI methodology and strategic planning using a fictional case study as an example. We will review how to identify a QI problem, define components of an effective problem statement, and identify stakeholders and core change team members. We will also describe three techniques used to perform root cause analyses—Ishikawa diagrams, Pareto charts and process mapping—and how they relate to preparing for a QI project. The next two papers in this series will focus on the execution of the QI project itself using rapid-cycle testing and on the evaluation and sustainability of QI projects.

ObjectiveTo determine parental experiences and preferences regarding the conduct of pediatric research in an emergency department (ED) setting.MethodsWe conducted a cross-sectional study of parents of children ages 0 – 14 years who visited the ED of a tertiary care children’s hospital. Parents completed a Web-based survey designed to assess perceptions regarding: 1) background/training of research personnel, 2) location and timing of research discussions, and 3) factors influencing their consent/refusal decision.ResultsParents totalling 339 were approached, and 227 (67%) surveys were completed. Overall, 87% (197/227; 95% confidence interval [CI] 83, 92) reported they would be comfortable being approached by a university student to discuss research. This proportion did not change when stratified by the child’s gender, illness severity, or season of visit. Whereas only 37% (84/227; 95% CI 31, 43) of respondents would be comfortable being approached in the waiting room, 68% (154/227; 95% CI 62, 75) would be comfortable if approached in a separate area of the main waiting room. The majority reported comfort with follow-up via email (83%; 188/227; 95% CI 78, 88) or telephone (80%; 182/227; 95% CI 75, 85); only 51% (116/227; 95% CI 44, 57) would be comfortable with a scheduled follow-up visit in the hospital. Participants identified potential complications or side effects as the most common reason for declining consent (69%; 157/227; 95% CI 63, 75).ConclusionsThe majority of parents are comfortable being approached by trained university students, preferably in a separate area of an ED waiting room, and email and telephone follow-ups are preferred over a scheduled re-visit.

Objectives The objective of this study was to describe the quality of emergency department (ED) care for pediatric patients with anaphylaxis. The secondary objectives were to describe (1) the clinical presentation of pediatric patients with anaphylaxis including the proportion of patients meeting each of the National Institute of Allergy and Infectious Diseases (NIAID) consensus criteria and subcriteria and (2) the Interrater reliability (IRR) for applying the NIAID criteria. Methods We conducted a retrospective cross-sectional chart review of patients seen in a pediatric ED during a 2-year period. All charts were reviewed by a trained chart reviewer with 10% abstracted by a second reviewer. Data were analyzed using descriptive statistics including proportions, medians, and interquartile range. Interrater reliability was calculated using Cohen unweighted κ or percent agreement. Results Of the 250 charts reviewed, 84% (211) met the NIAID criteria for anaphylaxis (IRR, 1.0). Only 68% of patients received epinephrine in the ED or within 3 hours of the ED visit. Adherence was poor and IRR was variable, for measures reflecting documentation of discharge instructions and follow-up with a specialist. The IRR of reviewers for determining which patients met the NIAID criteria overall and for each subcriterion was high. Conclusions Our findings highlight a gap between best practice and ED care. In addition, our results suggest that the NIAID criteria can reliably be used to retrospectively identify pediatric patients with anaphylaxis. Accurately identifying cases is a prerequisite for measuring gaps in management and developing interventions to improve care.

Samina Ali,1,2 Denise Thomson,3 Timothy A D Graham,4 Sean E Rickard,3 Antonia S Stang5 1Women and Children’s Health Research Institute, 2Department of Pediatrics, 3Cochrane Child Health Field, Department of Pediatrics, University of Alberta, Edmonton, 4Department of Emergency Medicine, 5Section of Emergency Medicine, Department of Pediatrics, University of Calgary, Calgary, AB, Canada Background: The high-paced, unpredictable environment of the emergency department (ED) contributes to errors in patient safety. The ED setting becomes even more challenging when dealing with critically ill patients, particularly with children, where variations in size, weight, and form present practical difficulties in many aspects of care. In this commentary, we will explore the impact of the health care providers’ emotional reactions while caring for critically ill patients, and how this can be interpreted and addressed as a patient safety issue. Discussion: ED health care providers encounter high-stakes, high-stress clinical scenarios, such as pediatric cardiac arrest or resuscitation. This health care providers’ stress, and at times, distress, and its potential contribution to medical error, is underrepresented in the current medical literature. Most patient safety research is limited to error reporting systems, especially medication-related ones, an approach that ignores the effects of health care provider stress as a source of error, and limits our ability to learn from the event. Ways to mitigate this stress and avoid this type of patient safety concern might include simulation training for rare, high-acuity events, use of pre-determined clinical order sets, and post-event debriefing. Conclusion: While there are physiologic and anatomic differences that contribute to patient safety, we believe that they are insufficient to explain the need to address critical life-threatening event-related patient safety issues for both adults and, especially, children. Many factors make patient safety during critical medical events distinct from general patient safety issues, but it is, perhaps, this heightened high-stress, emotional climate that is the most distinct and important part of all. We believe that consideration of this concept is essential when discussing safety improvement in critical medical events. Keywords: emergency department, pediatrics, patient safety, distress

Objective To systematically review the literature and determine frequencies of adverse drug events (ADE) associated with pediatric asthma medications. Methods Following PRISMA guidelines, we systematically searched six bibliographic databases between January 1991 and January 2017. Study eligibility, data extraction and quality assessment were independently completed and verified by two reviewers. We included randomized control trials (RCT), case-control, cohort, or quasi-experimental studies where the primary objective was identifying ADE in children 1 month– 18 years old exposed to commercial asthma medications. The primary outcome was ADE frequency. Findings Our search identified 14,540 citations. 46 studies were included: 24 RCT, 15 cohort, 4 RCT pooled analyses, 1 case-control, 1 open-label trial and 1 quasi-experimental study. Studies examined the following drug classes: inhaled corticosteroids (ICS) (n = 24), short-acting beta-agonists (n = 10), long-acting beta-agonists (LABA) (n = 3), ICS + LABA (n = 3), Leukotriene Receptor Antagonists (n = 3) and others (n = 3). 29 studies occurred in North America, and 29 were industry funded. We report a detailed index of 406 ADE descriptions and frequencies organized by drug class. The majority of data focuses on ICS, with 174 ADE affecting 13 organ systems including adrenal and growth suppression. We observed serious ADE, although they were rare, with frequency ranging between 0.9–6% per drug. There were no confirmed deaths, except for 13 potential deaths in a LABA study including combined adult and pediatric participants. We identified substantial methodological concerns, particularly with identifying ADE and determining severity. No studies utilized available standardized causality, severity or preventability assessments. Conclusion The majority of studies focus on ICS, with adrenal and growth suppression described. Serious ADE are relatively uncommon, with no confirmed pediatric deaths. We identify substantial methodological concerns, highlighting need for standardization with future research examining pediatric asthma medication safety.

Introduction: Prior research has shown that audit and feedback (A &F) can be an effective tool for practice change. However, questions remain about how to optimize A&F. The objectives of this project were to determine if: 1) there are differences in practice between physicians who do, and do not, consent to receive a confidential report on their practice and; 2) if there is a relationship between consenting physicians self-predicted and actual practice. Methods: This was a prospective, cross-sectional study embedded in a larger quality improvement (QI) initiative to align physician practice with best evidence in the emergency department (ED) care of infants with bronchiolitis. All physicians practicing in the ED of a tertiary care pediatric hospital were offered the opportunity to consent to receive an individual, confidential data report on their practice. Prior to receiving their data, consenting physicians completed a survey which asked them to predict the proportion of bronchiolitic patients for whom they ordered diagnostic tests or treatments. We used chi-squared testing to compare the proportion of consenting and non-consenting physicians whose diagnostic test (Chest X-ray (CXR), viral study) and treatment (steroid, Ventolin) ordering was above the median for all ED physicians. We used Pearsons correlation to assess the relationship between consenting physicians self -predicted and actual practice. Results: 56% (37/66) of physicians consented to receive a data report. The median proportion of patients with an x-ray ordered was 20%, 63% of non-consenters were above the median, compared to 36% of consenters (X2 (1, N=66)=4.91 p=0.03). For viral testing, 31% of patients had a test ordered, with 50% of non-consenters and 50% consenters above the median (( X2 (1, N=66) =0 p=1); 11% of patients had steroids ordered, with 53% of non-consenters and 47% of consenters above the median ( X2 (1, N=66)=0.24 p-0.621); and 18% of patients had Ventolin ordered, with 60% of non-consenters and 42% of consenters above the median ( X2 (1, N=66) =2.2 p=0.138). There was a moderate correlation between physicians predicted and actual practice with respect to viral testing (r=0.67), but minimal correlation for CXR (0.05), steroids (r=0.17) or Ventolin (r=0.33) ordering. Conclusion: The finding that physicians have a limited ability to accurately predict their own performance emphasizes the importance of providing physicians with feedback. However, our results suggest that the consent process may be a potential barrier to effective A &F.

Educators have long relied on the use of patient cases to illustrate key patient safety concepts to learners.1–3 These efforts engage clinician learners by harnessing the tradition of clinically based educational fora, such as morbidity and mortality rounds and other such case conferences. Teaching about the systems approach to patient safety in the context of compelling cases—a patient taken for someone else's invasive cardiology procedure, or a patient who died after her arterial line was flushed with insulin instead of heparin1 ,4—will have more impact than just outlining the Swiss cheese model of accident causation and describing the human factors perspective in investigating critical incidents. Engaging as these case-based approaches to teaching patient safety may be, they tend to focus on the more ‘technical’ aspects of patient safety such as teamwork and communication, principles of human factors engineering or the different stages of the medication management process in which errors can arise. Lost in such learning sometimes is the patient perspective, the voice that emphasises the importance of keeping the patients and families central to conversations about patient safety. More recently, published accounts of patient and provider stories relate their personal experiences with patient safety incidents.5–7 However, having actual patients tell their stories and interact directly with learners is a novel educational approach for patient safety training that warrants consideration for several important reasons. First, there is an obvious appeal to involving patients and families in health professions education because they provide an authentic perspective on avoidable harm resulting from patient safety incidents. Beyond that however, their involvement may serve to address some important challenges that educators face when implementing a patient safety educational programme. Some programmes struggle to make leaning about patient safety engaging or interesting, or find that learners fail to see the …

OBJECTIVE: Identifying gaps in care and improving outcomes for severely ill children requires the development of evidence-based performance measures. We used a systematic process involving multiple stakeholders to identify and develop evidence-based quality indicators for high acuity pediatric conditions relevant to any emergency department (ED) setting where children are seen. METHODS: A prioritized list of clinical conditions was selected by an advisory panel. A systematic review of the literature was conducted to identify existing indicators, as well as guidelines and evidence that could be used to inform the creation of new indicators. A multiphase, Rand-modified Delphi method consisting of anonymous questionnaires and a face-to-face meeting of an expert panel was used for indicator selection. Measure specifications and evidence grading were created for each indicator, and the feasibility and reliability of measurement was assessed in a tertiary care pediatric ED. RESULTS: The conditions selected for indicator development were diabetic ketoacidosis, status asthmaticus, anaphylaxis, status epilepticus, severe head injury, and sepsis. The majority of the 62 selected indicators reflect ED processes (84%) with few indicators reflecting structures (11%) or outcomes (5%). Thirty-seven percent (n = 23) of the selected indicators are based on moderate or high quality evidence. Data were available and interrater reliability acceptable for the majority of indicators. CONCLUSIONS: A systematic process involving multiple stakeholders was used to develop evidence-based quality indicators for high acuity pediatric conditions. Future work will test the reliability and feasibility of data collection on these indicators across the spectrum of ED settings that provide care for children.

Background. Fear of adverse events and occurrence of side effects are commonly cited by families and physicians as obstructive to appropriate use of pain medication in children. We examined evidence comparing the safety profiles of three groups of oral medications, acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids, to manage acute nonsurgical pain in children (Methods. A comprehensive search was performed to July 2015, including review of national data registries. Two reviewers screened articles for inclusion, assessed methodological quality, and extracted data. Risks (incidence rates) were pooled using a random effects model.Results. Forty-four studies were included; 23 reported on adverse events. Based on limited current evidence, acetaminophen, ibuprofen, and opioids have similar nausea and vomiting profiles. Opioids have the greatest risk of central nervous system adverse events. Dual therapy with a nonopioid/opioid combination resulted in a lower risk of adverse events than opioids alone.Conclusions. Ibuprofen and acetaminophen have similar reported adverse effects and notably less adverse events than opioids. Dual therapy with a nonopioid/opioid combination confers a protective effect for adverse events over opioids alone. This research highlights challenges in assessing medication safety, including lack of more detailed information in registry data, and inconsistent reporting in trials.

Reason for withdrawal from publication This protocol has been superseded by another on 'Different oral corticosteroid regimens for acute asthma' http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011801.pub2/abstract

Background Health-care professionals frequently recommend fever treatment regimens for children who either combine paracetamol and ibuprofen or alternate them.However, there is uncertainty about whether these regimens are better than using single agents and about the adverse effect profile of combination regimens. Objectives To assess the results and side effects of combining paracetamol and ibuprofen, or alternating them in consecutive treatments, compared with monotherapy for treating fever in children. Search methods In September 2013, we searched Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS and International Pharmaceutical Abstracts (2009-2011). Selection criteria We included randomized controlled trials that compared alternating or combined paracetamol and ibuprofen regimens with monotherapy in children with fever. Data collection and analysis One review author and two assistants independently screened the searches and applied the inclusion criteria. Two authors assessed risk of bias and graded the evidence independently. We conducted various analyses for different comparison groups (combined therapy versus monotherapy, alternating therapy versus monotherapy and combined therapy versus alternating therapy). Main results Six studies, enrolling 915 participants, are included. Compared to administering a single antipyretic alone, administering combined paracetamol and ibuprofen to febrile children can result in a lower mean temperature at 1 hour after treatment (mean difference -0.27 ∘C, 95% confidence interval -0.45 to -0.08, two trials, 163 participants, moderate quality evidence). If no further antipyretics are given, combined treatment probably also results in a lower mean temperature at 4 hours (mean difference -0.70 ∘C, 95% confidence interval -1.05 to -0.35, two trials, 196 participants, moderate quality evidence), and in fewer children remaining or becoming febrile for at least 4 hours after treatment (relative risk 0.08, 95% confidence interval 0.02 to 0.42, two trials, 196 participants, moderate quality evidence). Only one trial assessed a measure of child discomfort (fever, associated symptoms at 24 and 48 hours), but did not find a significant difference in this measure between the treatment regimens (one trial, 156 participants, evidence quality not graded). In practice, caregivers are often advised to initially provide a single agent (paracetamol or ibuprofen), and then provide a further dose of the alternative if the child;s fever fails to resolve or recurs. Giving alternating treatment in this manner may result in a lower mean temperature at 1 hour after the second dose (mean difference -0.60 ∘C, 95% confidence interval -0.94 to -0.26, two trials, 78 participants, low quality evidence), and may also result in fewer children remaining or becoming febrile for up to 3 hours after it is given (relative risk 0.25, 95% confidence interval 0.11 to 0.55, two trials, 109 participants, low quality evidence). One trial assessed child discomfort (mean pain scores at 24, 48 and 72 hours), finding that these mean scores were lower, with alternating therapy, despite fewer doses of antipyretic being given overall (one trial, 480 participants, low quality evidence) Only one small trial compared alternating therapy with combined therapy. No statistically significant differences were seen in mean temperature or in the number of febrile children at 1, 4 or 6 hours (one trial, 40 participants, very low quality evidence). In all the trials, there were no serious adverse events that were directly attributed to the medications used. Authors' conclusions There is some evidence that both alternating and combined antipyretic therapies may be more effective at reducing temperatures than monotherapy alone. However, the evidence for improvements in measures of child discomfort remains inconclusive. There is insufficient evidence to decide which of combined or alternating therapy might be more beneficial. Future research needs to measure child discomfort using standardized tools, and assess the safety of combined and alternating antipyretic therapies.

Introduction: Bronchiolitis is a viral respiratory infection and the most common reason for hospitalization of infants. Despite evidence that few interventions are beneficial in patients with bronchiolitis, other studies would have shown that a significant proportion of patients undergo various forms of low value care. This objective of this project was to 1. establish baseline management of bronchiolitis in the Calgary Zone, and 2. deliver audit and feedback (A&F) reports to pediatric emergency physicians (PEP) to identify opportunities and strategies for practice improvement. Methods: This retrospective cohort study included all patients 12 months old that presented to a Calgary emergency department or urgent care center with a diagnosis of bronchiolitis from April 1, 2013 to March 31, 2017. Using data from various electronic health data sources, we captured age, vital signs, CTAS, common therapeutic interventions (bronchodilators, steroids, antibiotics) and investigations (chest x-ray (CXR), viral studies, antibiotics). Results were stratified by site and by admission status. Descriptive statistics were used to report baseline characteristics and interventions. Interhospital ranges (IHR) were provided to compare different hospitals in the zone. For the A&F component of the project, consenting PEP received a report of both their individual and peer comparator data and an in-person multi-disciplinary facilitated feedback session. Results: We included 4023 patients from all 6 sites (range from 28 to 3316 patients). Admission rates were 21.7% (IHR 0-29%). Mean age was 5.4 months old. Bronchodilator use was 27.0% (IHR 21-41%). 22.0% of patients received a CXR (IHR 0-57%) and 30.3% had viral studies done (IHR range 0.8-33%). PEP had higher usage of viral studies (30% vs 5.7%), whereas non-PEP had higher CXR usage (46.2% vs 23.4%). 41 of 66 PEP consented to receive their individual A&F reports (62%). In the facilitated feedback session PEP 1. identified two areas (bronchodilators and viral studies) where improvements could be made and 2. discussed specific strategies to decrease practice variation and minimize low value care including development of a multi-disciplinary care pathway, alignment with in-patient management, education and repeated A&F reports. Conclusion: Significant variability exists in management of patients with bronchiolitis across different hospitals in our zone. A facilitated feedback session identified areas for improvement and multi-disciplinary strategies to reduced low value care for patients with bronchiolitis. Future phases of this project include repeated data in 6 months and implementation of a provincial care pathway for the management of bronchiolitis.

Introduction: Pediatric pain is often under-treated in emergency departments (EDs), which is known to cause short and long-term harm. A recent quality improvement collaborative (QIC) was successful in improving treatment of children’s pain across 4 EDs in our city. A new QIC was then formed among EDs across our province to improve treatment of presenting and procedural pain. Aims were to improve the proportion of children Methods: Invitations to participate in the QIC were sent to all 113 EDs in the province that treat children and had not participated in the previous QIC. Each site was asked to form a project team, participate in monthly webinars, develop key driver diagrams and project aims, undertake PDSA tests of change, and audit charts to assess performance. Sites are given a list of 20 randomly selected charts per month for audit. Audit data was entered into REDCap and uploaded to a provincial run chart dashboard. All participating sites received a “comfort kit” consisting of distraction items for children as well as educational materials. Measures of presenting pain included proportion of children Results: 34 of 113 invited sites (30%) agreed to participate, including rural and regional representation from all geographic zones; 4222 visits since June 2016 were analyzed. Implementation began June 2017. Comparing the first 4 months following implementation to the preceding year, the proportion of children receiving topical anesthetic prior to needles increased from 13% to 25% (pConclusion: This province-wide QIC has already resulted in significant progress toward aims during the first 4 months of implementation. The QIC approach shows promise for improving pain outcomes in children visiting diverse EDs across a province.

Introduction: Undertreated pain is known to cause short and long-term harm in children. Limb injuries are a common painful condition in emergency department (ED) patients, accounting for 12% of ED visits by children. Our city has one pediatric ED in a freestanding children’s hospital and 3 general ED’s that treat both adults and children. 68% of pediatric limb injuries in our city are treated in the pediatric ED and 32% are treated in a general ED. A quality improvement (QI) initiative was developed at the children’s hospital ED in April 2015 focusing on “Commitment to Comfort.” After achieving aims at the childrens hospital, a QI collaborative was formed among the pediatric ED and the 3 general ED’s to 1) improve the proportion of children citywide receiving analgesia for limb injuries from 27% to 40% and 2) reduce the median time to analgesia from 37 minutes to 15 minutes, during the time period of April-September, 2016. Methods: Data were obtained from computerized order entry records for children 0-17.99 years visiting any participating ED with a chief complaint of limb injury. Project teams from each site met monthly to discuss aims, develop key driver diagrams, plan tests of change, and share learnings. Implementation strategies were based on the Model for Improvement with PDSA cycles. Patient and family consultation was obtained. Process measures included the proportion of children treated with analgesic medication and time to analgesia; balancing measures were duration of triage and length of stay for limb injury and all patients. Site-specific run charts were used to detect special cause variation. Data from all sites were combined at study end to measure city-wide impact using 2 and interrupted time series analysis. Results: During the 3.5-year time period studied (April 1, 2014-September 30, 2017), there were 45,567 visits to the participating ED’s by children 0-17.99 years with limb injury. All visits were included in analysis. Special cause was detected in run charts of all process measures. Interrupted time series analysis comparing the year prior to implementation at the childrens hospital in April 2015 to the year following completion of implementation at the 3 general hospitals in October 2016 demonstrated that the proportion of patients with limb injury receiving analgesia increased from 27% to 40% (pConclusion: This multisite initiative emphasizing “Commitment to Comfort” was successful in improving pain outcomes for all children with limb injuries seen in city-wide ED’s, and was sustained for one year following implementation. A QI collaborative can be an effective method for spreading improvement. The project team is now spreading the Commitment to Comfort initiative to over 30 rural and regional EDs throughout the province through establishment of a provincial QI collaborative.

Objectives: The objective of this study was to identify markers of overcrowding in pediatric emergency departments (PEDs) according to expert opinion and then to use statistical methods to further explore the underlying construct of overcrowding. Methods: A cross-sectional survey of all PED directors (n = 12) and pediatric emergency medicine fellowship program directors (n = 10) across Canada was conducted to elicit expert opinion on relevant markers of emergency department (ED) crowding. The list of markers was reduced to those specific to the ED for which data could be extracted from one tertiary care PED from an existing computerized patient tracking system. Data representing 2,190 consecutive shifts and 138,361 patient visits were collected between April 2005 and March 2007. Common factor analysis (CFA) was used to determine the underlying factors that best represented overcrowding as determined by markers identified by experts in pediatric emergency medicine Results: The main markers of overcrowding identified by the survey included measures of patient volume (25%), ED operational processes (55%), and delays in transferring patients to inpatient beds (13%). Data collected on 41 markers were retained for the CFA. The results of the CFA indicated that the largest portion of variation in the data (48%) was accounted for by markers describing patient volumes and flow through the ED. Measures of admission delays accounted for a smaller proportion of variability (9%). Conclusions: The results suggest that for this tertiary PED, markers of ED operational processes and patient volume may be more relevant for determination of overcrowding than markers reflecting delays in transferring patients to inpatient beds. This study provides a foundation for further research on markers of overcrowding specific to the pediatric setting. ACADEMIC EMERGENCY MEDICINE 2010; 17:151–156 © 2010 by the Society for Academic Emergency Medicine