Objective To evaluate healthcare cost associated with a standardized mental healthcare bundle in two tertiary pediatric emergency departments (EDs) in Alberta, Canada. Methods We linked data from the two EDs and administrative health databases. Patients < 18 years presenting with mental health concerns were enrolled during two periods: pre-implementation (standard care) and implementation (mental health bundle). Healthcare resource utilization (HCRU) and costs were compared over 12 months following the initial ED visit. Results The study included 686 pre-implementation (mean age 12.6 years) and 692 implementation (mean age 13.0 years) patients with similar sex distribution (p = 0.65). Implementation patients had lower admission rates at the index ED visit (4.6% versus 9.8%; p < 0.001). During 1 year of follow-up, implementation patients had fewer hospitalizations (mean = 0.4 versus 0.5; p < 0.001), non-ED ambulatory care visits (mean = 2.7 versus 10.0; p < 0.001), and practitioner claims (mean = 34.3 versus 46.8; p = 0.001). Implementation patients had lower healthcare costs ($12,408 [95% CI $10,336-$14,479] versus $19,326 [95% CI $16,596-$22,056]; p < 0.001) attributable to lower hospitalization ($6845 [95% CI $5257-$8435] versus $9994 [95% CI $8205-$11,782]; p = 0.01), ambulatory care ($1711 [95% CI $1383-$2038] versus $4027 [95% CI $3326-$4727]; p < 0.001), and practitioner ($3851 [95% CI $3410-$4292] versus $5306 [95% CI $4676-$5935]; p < 0.001) expenses during the follow-up. After risk adjustments, care bundle was associated with a 40% [95% CI 26-52%] reduction in mental health-related healthcare costs (p < 0.001) and 37% (95% CI 23-49%) reduction in all-cause healthcare costs (p < 0.001). Conclusions Integrating a standardized mental healthcare bundle in pediatric EDs was associated with less healthcare use and cost savings. These findings support its broader use to enhance mental healthcare delivery in emergency settings.

BACKGROUND:Physician workload in pediatric emergency departments (PEDs) is associated with patient safety, quality of care, and clinician well-being, but is commonly inferred from proxy measures such as visit volume, acuity, or throughput metrics that incompletely capture the contextual and cognitive demands of clinical care. The Standardized Workload Assessment Metric for Pediatric Emergency Departments (SWAMPED) was developed to quantify workload at the level of discrete clinical tasks. We derived workload estimates and evaluated the reliability, precision, and contextual responsiveness of SWAMPED. METHODS:We conducted a multicenter cross-sectional study of PED physicians at tertiary children's hospitals within the Pediatric Emergency Research Canada network. Participants independently scored 46 care components using the NASA Task Load Index, a validated multidimensional instrument that measures perceived workload associated with a specific task (in this case a clinical care component) accounting for six domains of effort (mental, physical, time, effort, performance, and frustration). Six extrinsic patient and systems-level modifiers were assessed for their impact on component-level workload. We assessed score distributions, interrater agreement using intraclass correlation coefficients (ICC), precision of component estimates, and extrinsic modifiers' effects using mixed-effects models. RESULTS:Sixty-two physicians from 11 sites participated. Interrater agreement across care components was good (ICC: 0.69, 95% CI: 0.60-0.78). Mean workload scores varied across care components (range 22.1-99.5) with high precision (95% CI margin of error of 2.5-6.5 points; relative margin 5%-10%). Most components demonstrated increased workload in the presence of extrinsic modifiers, while intrinsic physician characteristics were not associated with significant differences in workload scores. CONCLUSIONS:SWAMPED generated reliable and precise, task-specific workload estimates and demonstrated sensitivity to clinically relevant contextual modifiers. This approach enables quantitative assessment of physician workload at the task level and provides a foundation for future investigations linking workload to clinical outcomes, clinician performance, and health system planning.

BackgroundAsthma exacerbation is a major cause of emergency department visits in children and adolescents. Most of the existing asthma prediction scores and biomarkers are designed to predict severe exacerbations in the medium to long term. Mobile health (mHealth) is a promising approach for integrating real-time, multimodal data to improve the prediction of asthma exacerbation. Using mHealth can enable the identification of at-risk children and the implementation of timely interventions. ObjectiveThe primary objective of the Mobile Health for Kids With Asthma (MoKA) study is to develop a validated predictive model for imminent asthma exacerbation in children using multimodal data, including participant-reported questionnaires through the RespiSentinel mobile app, augmented with publicly sourced environmental and epidemiological data. Furthermore, we will evaluate the association between the frequency of nocturnal cough measured in real time and asthma control and severe asthma exacerbation, and the acceptability of the RespiSentinel app in asthma self-management. MethodsThis is a prospective cohort study with in-person and remote recruitment at 7 tertiary pediatric centers in Canada. Parents of children aged between 1 and 17 years, as well as children who have experienced at least one wheezing episode or asthma exacerbation during the 12 months before recruitment, will be eligible to participate (estimated number of children: n=2000). The planned duration of study participation is 6 months following the date of enrollment (cohort entry), regardless of the number of asthma exacerbations during the follow-up period. The primary outcome will be asthma exacerbation defined by asthma symptoms requiring systemic corticosteroid use and an urgent care or emergency department visit or hospitalization. The predictive model will be created using questionnaire data on asthma control via the RespiSentinel app as well as by integrating publicly available local daily data on air pollutant levels (National Air Pollution Surveillance Program) and weekly prevalence of respiratory viruses (National Canadian Respiratory Virus Detection Surveillance Program). Nocturnal cough frequency will be determined by using nighttime audio recordings, and their contribution to predict imminent asthma exacerbation will be evaluated. Acceptability of the RespiSentinel app will be assessed through an app-based questionnaire. ResultsWe will train and validate an asthma exacerbation prediction model using multimodal data sources. This approach may help patients, their families, and health professionals anticipate upcoming loss of asthma control and take the necessary steps to prevent a severe asthma exacerbation. ConclusionsThe MoKA study will harness real-time mHealth data to identify children at imminent risk of asthma exacerbation with the ultimate goal of designing timely interventions to prevent morbidity in this group of patients.

Importance The emergency department (ED) is an important safety net for children experiencing mental and behavioral health crises and can serve as a navigational hub for families seeking support for these concerns. Objectives To evaluate the outcomes of a novel mental health care bundle on child well-being, satisfaction with care, and health system metrics. Design, Setting, and Participants Nonrandomized trial of 2 pediatric EDs in Alberta, Canada. Children younger than 18 years with mental and behavioral health presentations were enrolled before implementation (preimplementation: January 2020 to January 2021), at implementation onset (run-in: February 2021 to June 2021), and during bundle delivery (implementation: July 2021 to June 2022). Intervention The bundle involved risk stratification, standardized mental health assessments, and provision of an urgent follow-up appointment after the visit, if required. Main Outcomes and Measures The primary outcome, child well-being 30 days after the ED visit, was assessed using the Stirling Children’s Wellbeing Scale (children aged <14 years) or Warwick-Edinburgh Mental Wellbeing Scale (children aged 14-17 years). Change in well-being between the preimplementation and implementation periods was examined using interrupted time-series analysis and multivariable modeling. Changes in health system metrics (hospitalization, ED length of stay [LOS], and revisits) and care satisfaction were also examined. Results A total of 1412 patients (median [IQR] age, 13 [11-15] years), with 715 enrolled preimplementation (390 [54.5%] female; 55 [7.7%] First Nations, Inuit, or Métis; 46 [6.4%] South, Southcentral, or Southeast Asian; and 501 [70.1%] White) and 697 enrolled at implementation (357 [51.2%] female; 51 [7.3%] First Nations, Inuit, or Métis; 39 [5.6%] South, Southcentral, or Southeast Asian; and 511 [73.3%] White) were included in the analysis. There were no differences between study periods in well-being. Reduced well-being z scores were associated with mood disorder diagnosis (standardized mean difference, −0.14; 95% CI, −0.26 to −0.02) and nonbinary gender identity (standardized mean difference, −0.41; 95% CI, −0.62 to −0.19). The implementation period involved fewer hospitalizations (difference in hospitalizations, −6.9; 95% CI, −10.4 to −3.4) and longer ED LOS (1.1 hours; 95% CI, 0.7 to 1.4 hours). There were no differences between study periods in ED revisits or care satisfaction. Conclusions and Relevance In this study, the delivery of a care bundle was not associated with higher child well-being 30 days after an ED visit. Hospitalizations did decrease during bundle delivery, but ED LOS did not. These health system findings may have been affected by broader changes in patient volumes and flow processes that occurred during the COVID-19 pandemic, which took place as the study was conducted. Trial Registration ClinicalTrials.gov Identifier: NCT04292379

BACKGROUND:Little is known about changes in child well-being and family quality of life (QoL) among children seeking emergency department care because of mental health concerns over the course of the pandemic. METHODS:Prospective cohort study of children < 18 who visited two paediatric EDs in Alberta, Canada, for an acute mental health concern. Early and late pandemic time periods were defined as 15 March 2020-14 March 2021 and 1 July 2021-30 June 2022, respectively. The Stirling Children's Well-being and Warwick-Edinburgh Mental Well-being scales quantified well-being; the Family Quality of Life Scale assessed family QoL. These scales were completed as soon as possible following the ED visit. Linear regression models assessed the association between pandemic period and the change in well-being and family QoL. RESULTS:One thousand four hundred four children were enrolled during the study time periods (50.4% early, 49.6% late). Seventy-two percent (1009/1404) of participants were White, 53.8% (744/1404) were female, and the median age was 13 (IQR, 11-15) years. Well-being remained unchanged between time periods, whereas family QoL was lower in the late pandemic time period than in the early period (mean difference: -2.16, 95% CI: -3.79, -0.53; p = 0.01). Among children < 13 years, previous mental health care and requiring inpatient admission were negatively associated with well-being. Having an autism diagnosis and a comprehensive ED mental health evaluation were negatively associated with well-being in older children. CONCLUSIONS:Reduced family QoL may signal stressors experienced by caregivers and the lingering consequences of the pandemic. Resources that address well-being and support the family unit are needed to improve the mental health of children.

Importance The emergency department (ED) is an important safety net for children experiencing mental and behavioral health crises and can serve as a navigational hub for families seeking support for these concerns. Objectives To evaluate the outcomes of a novel mental health care bundle on child well-being, satisfaction with care, and health system metrics. Design, Setting, and Participants Nonrandomized trial of 2 pediatric EDs in Alberta, Canada. Children younger than 18 years with mental and behavioral health presentations were enrolled before implementation (preimplementation: January 2020 to January 2021), at implementation onset (run-in: February 2021 to June 2021), and during bundle delivery (implementation: July 2021 to June 2022). Intervention The bundle involved risk stratification, standardized mental health assessments, and provision of an urgent follow-up appointment after the visit, if required. Main Outcomes and Measures The primary outcome, child well-being 30 days after the ED visit, was assessed using the Stirling Children's Wellbeing Scale (children aged <14 years) or Warwick-Edinburgh Mental Wellbeing Scale (children aged 14-17 years). Change in well-being between the preimplementation and implementation periods was examined using interrupted time-series analysis and multivariable modeling. Changes in health system metrics (hospitalization, ED length of stay [LOS], and revisits) and care satisfaction were also examined. Results A total of 1412 patients (median [IQR] age, 13 [11-15] years), with 715 enrolled preimplementation (390 [54.5%] female; 55 [7.7%] First Nations, Inuit, or M & eacute;tis; 46 [6.4%] South, Southcentral, or Southeast Asian; and 501 [70.1%] White) and 697 enrolled at implementation (357 [51.2%] female; 51 [7.3%] First Nations, Inuit, or M & eacute;tis; 39 [5.6%] South, Southcentral, or Southeast Asian; and 511 [73.3%] White) were included in the analysis. There were no differences between study periods in well-being. Reduced well-being z scores were associated with mood disorder diagnosis (standardized mean difference, -0.14; 95% CI, -0.26 to -0.02) and nonbinary gender identity (standardized mean difference, -0.41; 95% CI, -0.62 to -0.19). The implementation period involved fewer hospitalizations (difference in hospitalizations, -6.9; 95% CI, -10.4 to -3.4) and longer ED LOS (1.1 hours; 95% CI, 0.7 to 1.4 hours). There were no differences between study periods in ED revisits or care satisfaction. Conclusions and Relevance In this study, the delivery of a care bundle was not associated with higher child well-being 30 days after an ED visit. Hospitalizations did decrease during bundle delivery, but ED LOS did not. These health system findings may have been affected by broader changes in patient volumes and flow processes that occurred during the COVID-19 pandemic, which took place as the study was conducted. Trial RegistrationClinicalTrials.gov Identifier: NCT04292379

OBJECTIVES:We aimed to develop a comprehensive list of patient care components performed by pediatric emergency department (PED) physicians that could be individually scored on their subjective workload using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). These "care components," alongside patient and environmental factors that influence workload ("modifiers"), will form the basis of the Standardized Workload Assessment Metric for Pediatric Emergency Departments (SWAMPED). We sought to obtain preliminary workload scores for each care component and assess the face validity of the NASA-TLX-derived workload tool. METHODS:After establishing a working list of "care elements" and modifiers, we convened an expert panel during a 3-day workshop to curate a comprehensive list of PED patient care components and modifiers affecting physician workload using a modified Delphi process. Experts completed a pilot version of the NASA-TLX-derived workload survey for each care component. A virtual follow-up was held 5 months after the initial meeting to finalize the list of modifiers and care components. RESULTS:Of the 93 initial care elements and 75 modifiers, 46 care components were retained, alongside 6 final modifiers. Preliminary workload scores showed "high acuity, low occurrence procedures (cricothyroidotomy, thoracotomy, pericardiocentesis, burr hole, etc.)," with the highest median workload score of 106, while "immobilization device simple (prefabricated)" had the lowest median workload score of 22. CONCLUSIONS:The SWAMPED, derived through expert consensus, holds promise as a standardized assessment tool for PED physician workload. Validation studies involving larger cohorts are crucial for refining the SWAMPED and allowing widespread adoption of this novel quantitative workload metric.

Medical mistakes made while in a state of cognitive fatigue result in diagnostic errors, psychological distress, poor patient outcomes, and potentially, loss of life. To date, cognitive fatigue in health professionals is assessed via self-report; however, the reliability and validity of these measures are often challenged. Here we propose the use of mobile electroencephalography (mEEG) in a medical context as an objective cognitive fatigue assessment that is cost effective, reliable, and efficient. We had medical students complete a simulated night on call during which they diagnosed a series of simulated medical cases. Before and after their shift, we assessed cognitive fatigue using both behavioural and mEEG measures. Our results demonstrate a decrease in the amplitude of a neural response sensitive to cognitive fatigue from the start to the end of the simulated night on call — a finding associated with an increase in cognitive fatigue. Interestingly, we observed no reltionship between the neural response and subjective self-reported cognitive fatigue scores, supporting the need for objective as opposed to subjective measures when asasessing cognitive fatigue.

Objectives Despite being a frequent entry point of care, it remains unknown if families' needs are being met across pediatric emergency departments (PEDs). Study objectives were to describe caregivers' perceived overall PED experience and needs and to what extent these needs were met. Methods This descriptive, cross-sectional survey with medical record review was conducted in 10 Canadian PEDs. Caregivers completed electronic surveys in the PED and within 7 days postvisit. The primary outcome was the degree to which caregivers' overall needs were met in the PED. Results A total of 2005 caregivers participated; mean age was 37.8 (standard deviation 7.7) years and 74.3% (1462/1969) were mothers. Mean child age was 5.9 (standard deviation 5.1) years; 51.9% (1040/2003) were male. The median [interquartile range (IQR)] length of stay was 3.9 (2.6–6.1) hours. A total of 22.1% (322/1454) of caregivers reported that their overall needs were not adequately met (Likert scale 1–3/5). The top unmet needs during a PED visit were prompt medical care [20.3% (194/955)], access to practical items [16.8% (160/955)], and effective communication surrounding care [8.7% (83/955)]. Caregiver needs being met were associated with their child's needs being met [odds ratio (OR) 21.2 (13.1–34.2)], child's pain being well managed [OR 3.7 (2.4–5.6)], and satisfaction with overall length of stay [OR 2.6 (1.8–3.8)]. Conclusions Almost one fourth of caregivers report their overall needs were not fully met. Improving the quality of PED experience through better communication (ie, wait time delays, medical updates) and earlier pain care initiation may improve family experiences while policymakers work nationally to address lengthy wait times.

OBJECTIVE: To evaluate how social behaviors relate to SARS-CoV-2 test positivity across pediatric age groups. METHODS: Multicenter, cross-sectional study recruiting children < 18 years old tested for SARS-CoV-2 infection in emergency departments between 2020 and 2022. We used multivariate logistic regression to assess how self-reported social behaviors affect SARSCoV-2 test positivity across four age groups. Causal mediation analysis quantified how mask-wearing and presence of an infected close contact mediated the SARS-CoV-2 risk of given behaviors. RESULTS: Seven thousand two hundred and seventy two children were enrolled and 1457 (20.0%) tested positive for SARS-CoV-2. Attending a social gathering was associated with increased odds (aOR 1.64, 95% CI: 1.05, 2.57) of SARS-CoV-2 positivity among children aged 5- < 12 years. Those attending in-person school/daycare were less likely to test positive for SARS-CoV-2 across all age categories. Attending childcare was associated with 16.3% (95% CI: -21.0%, -11.2%) and 9.0% (95% CI: -11.6%, -6.5%) reductions in the probability of testing positive for SARS-CoV-2 infection, with 53.5% (95% CI: 39.2%, 73.9%) and 22.8% (95% CI: 9.7%, 36.2%) of the effects being mediated by the presence of a close contact among < 1 year and 1- < 5 year age groups, respectively. Masking in public mediated the association between childcare attendance and SARS-CoV-2 positivity in children aged < 1 year. CONCLUSIONS: Attending social gatherings increased the risk of SARS-CoV-2 test positivity in 5- < 12-year-old children, but in-person daycare/school was associated with a reduced odds of testing positive across all ages. Settings with high public health adherence (ie, schools) reduced the risk of testing positive for SARS-CoV-2, possibly from reduced close contact with SARS-CoV-2 positive individuals.

Objectives: We aimed to develop a comprehensive list of patient care components performed by pediatric emergency department (PED) physicians that could be individually scored on their subjective workload using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). These “care components,” alongside patient and environmental factors that influence workload (“modifiers”), will form the basis of the Standardized Workload Assessment Metric for Pediatric Emergency Departments (SWAMPED). We sought to obtain preliminary workload scores for each care component and assess the face validity of the NASA-TLX-derived workload tool. Methods: After establishing a working list of “care elements” and modifiers, we convened an expert panel during a 3-day workshop to curate a comprehensive list of PED patient care components and modifiers affecting physician workload using a modified Delphi process. Experts completed a pilot version of the NASA-TLX-derived workload survey for each care component. A virtual follow-up was held 5 months after the initial meeting to finalize the list of modifiers and care components. Results: Of the 93 initial care elements and 75 modifiers, 46 care components were retained, alongside 6 final modifiers. Preliminary workload scores showed “high acuity, low occurrence procedures (cricothyroidotomy, thoracotomy, pericardiocentesis, burr hole, etc.),” with the highest median workload score of 106, while “immobilization device simple (prefabricated)” had the lowest median workload score of 22. Conclusions: The SWAMPED, derived through expert consensus, holds promise as a standardized assessment tool for PED physician workload. Validation studies involving larger cohorts are crucial for refining the SWAMPED and allowing widespread adoption of this novel quantitative workload metric.

This secondary analysis examines the findings of a nonrandomized clinical trial assessing family quality of life after an emergency department visit.

Objectives:To evaluate the association between race and SARS-CoV-2 test positivity and outcomes in children. Study Design:Secondary analysis of a prospective cohort study recruiting children < 18 years, tested for SARS-CoV-2 between August 2020 and February 2022, in Canadian pediatric emergency departments. Race was self-reported by participants. The primary outcome was SARS-CoV-2 test positivity. Secondary outcomes were medical interventions and hospitalization within 14 days of index visit, and post-COVID condition (PCC) at 90-day follow-up. Associations were evaluated using multi-level logistic regression models. Results:Seven thousand and two-thirty three children underwent SARS-CoV-2 testing; median age was 2.0 years (IQR: 1.0-5.0), and 3366 (46.5%) were female. 1440 (19.9%) children tested positive for SARS-CoV-2, 776 (10.7%) were hospitalized, and 153 (13.2%) test-positive children experienced PCC. Compared to White children, most racial minority groups were more likely to test positive for SARS-CoV-2 (Middle Eastern aOR [95% CI] 2.62 [2.07, 3.32], Black aOR 2.36 [1.85, 3.03], Latin American aOR 2.23 [1.58, 3.15], South Asian aOR 2.17 [1.67, 2.82], Indigenous aOR 2.09 [1.29, 3.37], Southeast Asian aOR 1.82 [1.27, 2.62], Multiracial aOR 1.35 [1.07, 1.69], and had lower odds of medical interventions. Only Indigenous children were at higher odds of hospitalization than White children (aOR [95% CI]: 2.48 [1.03, 5.95]). Black children were less likely to report PCCs than White children (aOR 0.44 [0.22-0.86]). Conclusions:Racial disparities exist in SARS-CoV-2 test positivity and outcomes among Canadian children seeking emergency care. A better understanding of the factors contributing to these differences is needed to promote equitable health across the population.

Objective:It remains unclear whether emerging mental health concerns in children infected with SARS-CoV-2 are a direct result of the infection or due to the indirect effects of the pandemic. Therefore, we sought to assess the frequency of new diagnoses of anxiety and/or depression among children diagnosed with and without SARS-CoV-2 infection who were tested in pediatric emergency departments. Methods:A prospective cohort study with 6- and 12-month follow-ups was conducted across 14 Canadian tertiary-care pediatric emergency departments of the Pediatric Emergency Research Canada (PERC) network. The study included children aged <18 years who were tested for SARS-CoV-2 infection between August 2020 and February 2022. The primary outcome was the diagnosis of anxiety and/or depression reported during follow-up. The surveys incorporated a modified version of the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) Long-COVID Pediatric Questionnaire. Results:Among the participants who were eligible for 6- and 12-month follow-ups, 64.7% (268/414) of SARS-CoV-2-positive and 71.9% (743/1,033) of SARS-CoV-2-negative participants completed follow-up at these time points, respectively. The median age was 7.0 [inter-quartile range (IQR): 5.0-11.0] years, and 54.2% (548/1,011) were male. New diagnoses of anxiety and/or depression reported on either survey did not differ significantly between test-positive (4.1%, 11/268) and test-negative (2.8%; 21/743) participants [difference = 1.3% (95% CI: -1.3 to 4.2)]. There was a higher prevalence of new diagnoses of anxiety and/or depression among SARS-CoV-2-negative participants aged ≥12 years relative to those aged <12 years [8.7% (13/149) vs. 1.3% (8/594); difference = 7.4%; 95% CI of the difference = 3.0-12.5], but not among SARS-CoV-2-positive participants [4.4% (2/45) vs. 4.0% (9/223); difference = 0.4%; 95% CI of the difference = -5.6 to 9.4]. At 6 or 12 months, SARS-CoV-2-positive participants were more likely to experience confusion and/or lack of concentration, abdominal pain, and insomnia. Conclusions:Although no association was found between SARS-CoV-2 infection and new diagnoses of anxiety and/or depression, SARS-CoV-2-positive participants were more likely to experience confusion/lack of concentration, abdominal pain, and insomnia. This finding, in the context of an increased prevalence of new diagnoses of anxiety and depression, underscores the impacts of societal changes on the mental health of children. Our finding that some non-specific symptoms were more frequently reported by SARS-CoV-2-positive participants emphasizes the need for further investigation of the underlying pathophysiologic mechanisms.

Abstract Background Discharge communication is essential to convey information regarding the care provided and follow-up plans after a visit to a hospital emergency department (ED), but it can be lacking for visits for pediatric mental health crises. Our objective was to co-design and conduct usability testing of new discharge communication interventions to improve pediatric mental health discharge communication. Methods The study was conducted in two phases using experience-based co-design (EBCD). In phase 1 (Sep 2021 to Jan 2022), five meetings were conducted with a team of six parents and two clinicians to co-design new ED discharge communication interventions for pediatric mental health care. Thematic analysis was used to identify patterns in team discussions and participant feedback related to discharge communication improvement and the Capability, Opportunity, Motivation, Behavior (COM-B) model was used to identify strategies to support the delivery of the new interventions. After meeting five, team members completed the Public and Patient Engagement Evaluation Tool (PPEET) to evaluate the co-design experience. In phase 2 (Apr to Jul 2022), intervention usability and satisfaction were evaluated by a new group of parents, youth aged 16–24 years, ED physicians, and nurses (n = 2 of each). Thematic analysis was used to identify usability issues and a validated 5-point Likert survey was used to evaluate user satisfaction. Evaluation results were used by the co-design team to finalize the interventions and delivery strategies. Results Two discharge communication interventions were created: a brochure for families and clinicians to use during the ED visit, and a text-messaging system for families after the visit. There was high satisfaction with engagement in phase 1 (overall mean PPEET score, 4.5/5). In phase 2, user satisfaction was high (mean clinician score, 4.4/5; mean caregiver/youth score, 4.1/5) with both interventions. Usability feedback included in the final intervention versions included instructions on intervention use and ensuring the text-messaging system activates within 12–24 h of discharge. Conclusions The interventions produced by this co-design initiative have the potential to address gaps in current discharge practices. Future testing is required to evaluate the impact on patients, caregivers, and health care system use after the ED visit.

To optimize the identification of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children, specimen collection and testing method are crucial considerations. Ideally, specimen collection is easy and causes minimal discomfort, and the laboratory approach is simple, accurate, and rapid. In this prospective cohort study we evaluated the accuracy of a point-of care nucleic acid device using caregiver/patient self-collected buccal swabs. Participants were recruited in 14 Canadian tertiary care pediatric emergency departments. Children <18 years of age deemed to require SARS-CoV-2 testing were eligible. Caregivers or the patient-collected buccal swabs which were tested on the ABBOTT ID NOW. The reference standard was nasopharyngeal swab specimens collected by a healthcare provider tested via laboratory reverse transcription PCR (RT-PCR). We enrolled 2,640 study participants and 14.4% (381/2,640) were SARS-CoV-2 RT-PCR-positive. Eight percent (223/2,640) and 85.0% (2,244/2,640) were concordant test-positive and concordant test-negative, respectively. Sensitivity and specificity of the investigational approach were 58.5% [95% confidence interval (CI): 53.4, 63.5] and 99.3% (95% CI: 98.9, 99.6), respectively. Cycle threshold values were lower among concordant [median 17 (15, 21)] relative to discordant [median 30 (22, 35)] swabs (P < 0.001). Sensitivity was greatest among children <4 years of age, when caregivers performed the swabs, among unvaccinated children, and those with shorter symptom duration. Across multiple pain measures, less pain was associated with buccal swab testing. Although accuracy of the buccal swab point-of-care SARS-CoV-2 test was good and negative agreement was excellent, sensitivity was only 58.5%. Concordance was greater among those with higher viral loads, and the approach involving buccal swabs was less painful.IMPORTANCETo optimize the identification of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children, specimen collection and testing method are crucial considerations. Ideally, specimen collection is easy and causes minimal discomfort, and laboratory approach is simple, accurate, and rapid. We evaluated the accuracy and pain associated with buccal swab specimen collection by caregivers or children themselves who were tested using a point-of-care isothermal nucleic acid amplification SARS-CoV-2 test. This novel approach was compared to nasopharyngeal swab specimens tested using laboratory-based PCR tests. While negative agreement was excellent, positive percent agreement was less than 60%. Concordance was greater among those with higher viral loads, and thus, sensitivity is excellent when transmissibility is more likely to occur. Importantly, the approach involving buccal swabs was significantly less painful, and thus, children and their caregivers are more likely to agree to testing using such an approach.CLINICAL TRIALSRegistered at ClinicalTrials.gov (NCT05040763).

OBJECTIVESTo describe and compare caregiver perceptions of their emergency department (ED) experiences with and without child life specialist (CLS) involvement in their child’s overall care.STUDY DESIGNA descriptive cross-sectional survey of caregivers of children 0-17 years at a tertiary care pediatric ED was completed from March to August 2021. Survey themes included perceived experience and satisfaction, and impact of child life specialists.RESULTSA total of 179 caregivers completed the survey; mean age was 38.9 years (SD 8.4), and 72.6% (122/179) were mothers. Caregivers of children with CLS involvement (CLS+) ranked their overall experience (p= 0.021) and satisfaction (p= 0.009) higher than without CLS involvement (CLS -). More CLS+ caregivers ranked their experience (57.6%, 34/61) and their satisfaction (79.7%, 47/61) as excellent (5/5 Likert scale rating), compared to CLS- caregivers (37.7%, 40/115 and 56.6%, 60/115 respectively). CLS+ families were more likely to be offered non-pharmacologic interventions (e.g., iPad, sensory lights, toys) (98.4% vs 31.3%, p=0.003); they were also more likely to have a healthcare worker explore their feelings and fears (52.5% vs 27.0%, p=0.0008), help them prepare for a procedure or exam (73.8% vs 31.3%, p<0.0001), provide distraction techniques (70.5% vs 19.1%, p<0.0001), offer strategies to help coping (47.5% vs 14.8%, p<0.0001), or provide play opportunities (55.7% vs 9.6%, p<0.0001).CONCLUSIONSCLS involvement in children’s ED care is associated with higher caregiver satisfaction and experience, beyond previously reported procedural distress management. Efforts to increase availability of CLSs should be made to better family experiences in the ED.

Pain is a common reason for attendance to the emergency department; however, pediatric specific data on the prevalence, location, and etiology of painful presentations are limited in the literature. Therefore, the objective of this study was to determine the prevalence of pain-related presentations to pediatric emergency departments during the triage process and characterize the anatomical locations and organ systems most affected by pain in a modern cohort. A two-center health record review of triage documentation was conducted at Canadian pediatric emergency departments. All children (< 18 years) were eligible for inclusion. Data were extracted from administrative sources with one week of consecutive patients included every 3 months over a one-year timeframe. Regression analyses were completed to identify variables associated with painful presentations and analgesia provision during the triage process. A total of 7208 emergency department presentations were included. Median [IQR] child age was 5.2 [1.9, 11.8] years and 53.2

14% of children with SARS-CoV-2 infections had radiographic pneumonia. Hypoxemia, cough, higher temperature, and older age were associated with pneumonias. In children tested, SARS-CoV-2 test results were not associated with radiographic pneumonia.

ObjectivesTo describe the extent to which caregivers' emotional and communication needs were met during pediatric emergency department (PED) visits. Secondary objectives included describing the association of caregiver emotional needs, satisfaction with care, and comfort in caring for their child's illness at the time of discharge with demographic characteristics, caregiver experiences, and ED visit details.Study designElectronic surveys with medical record review were deployed at ten Canadian PEDs from October 2018 -March 2020. A convenience sample of families with children <18 years presenting to a PED were enrolled, for one week every three months, for one year per site. Caregivers completed one in-PED survey and a follow-up survey, up to seven days post-visit.ResultsThis study recruited 2005 caregivers who self-identified as mothers (74.3%, 1462/1969); mean age was 37.8 years (SD 7.7). 71.7% (1081/1507) of caregivers felt their emotional needs were met. 86.4% (1293/1496) identified communication with the doctor as good/very good and 83.4% (1249/1498) with their child's nurse. Caregiver involvement in their child's care was reported as good/very good 85.6% (1271/1485) of the time. 81.8% (1074/1313) of caregivers felt comfortable in caring for their child at home at the time of discharge. Lower caregiver anxiety scores, caregiver involvement in their child's care, satisfactory updates, and having questions adequately addressed positively impacted caregiver emotional needs and increased caregiver comfort in caring for their child's illness at home.ConclusionApproximately 30% of caregivers presenting to PEDs have unmet emotional needs, over 15% had unmet communication needs, and 15% felt inadequately involved in their child's care. Family caregiver involvement in care and good communication from PED staff are key elements in improving overall patient experience and satisfaction.