BACKGROUND:In high-income countries, critical illness in children is rare, and often difficult for physicians to distinguish from common minor illness until late in the disease. Parents or caregivers are well positioned to detect early and subtle signs of deterioration, but the relationship between their concerns and patient outcomes is unknown. We aimed to examine the relationship between documented caregiver concern about clinical deterioration and critical illness in children presenting to hospital. METHODS:This prospective observational cohort study was conducted in the tertiary paediatric emergency department and inpatient paediatric wards at Monash Children's Hospital, Melbourne, Australia. We included patients younger than 19 years with a complete medical record, with a documented response to the question "Are you worried your child is getting worse?" asked to caregivers during their child's emergency department visit or hospital admission. The primary objective of this study was to examine the relationship between caregiver concern for clinical deterioration and critical illness, defined as intensive care unit admission, in paediatric patients presenting to hospital. Secondary objectives were to determine the relationship between caregiver concern for clinical deterioration and mechanical ventilation or death of the child, and to compare documented caregiver concern for deterioration with standard predictors of deterioration, such as abnormal vital signs. Multivariable analysis assessed whether caregiver concern for clinical deterioration was associated with intensive care unit (ICU) admission, mechanical ventilation, or death for all included patients. FINDINGS:In 26 months, from Nov 1, 2020 to Dec 31, 2022, 79 166 children younger than 19 years presented to the emergency department. 433 children were excluded due to transfer to a different hospital and 4888 were excluded as there were no sets of vital signs recorded after triage. Of the remaining 73 845 children with eligible emergency department presentations, 24 239 had at least one documented response for parent or caregiver concern (11 431 [47·2%] males and 12 808 [52·8%]) females). There were a total of 189 708 responses, and 8937 (4·7%) of these indicated concern for clinical deterioration. Compared with patients with caregivers without documented concerns, those with a caregiver reporting concern for clinical deterioration were more likely to be admitted to the ICU (6·9% [326/4721] vs 1·8% [352 of 19 518]), to be mechanically ventilated (1·1% [53 of 4721] vs 0·2% [48 of 19 518]), or die during admission (0·1% [five of 4721] vs 0·02% [four of 19 518]). Multivariable analysis showed caregiver concern for clinical deterioration was associated with ICU admission (adjusted odds ratio [aOR] 1·72 (1·40-2·11) and mechanical ventilation (aOR 1·85 (1·36-3·15), but not death (aOR 1·02 (0·18-5·81). After adjustment for other variables, caregiver concern (aOR 1·72 [95% CI 1·40-2·11]) was more strongly associated with ICU admission than any abnormal vital sign (ranging from aOR 1·12 [95% CI 1·08-1·17] for abnormal heart rate to aOR 1·26 [1·21-1·32] for abnormal respiratory rate). INTERPRETATION:Caregiver concern for clinical deterioration is associated with critical illness in paediatric patients and, after adjusting for variables including abnormal vital signs, had a strong association with ICU admission and mechanical ventilation. Rapid response systems should incorporate proactive assessment of parent or caregiver concerns for deterioration. FUNDING:Australian Government Medical Research Future Fund and Equity Trustees: The Monash Partners Children's Acute Care Data Project.

OBJECTIVE:Documentation of clinical impressions in ED electronic medical records is essential for diagnostic decision-making and effective patient management. We sought to evaluate the completeness of clinical impression documentation in initial ED medical assessments to identify gaps and inform future multimodal research interventions. METHODS:A structured retrospective medical record review of 500 randomly selected adult patients who presented to four Australian EDs between 1-31 August 2024 was conducted. The primary outcome was a documented clinical impression in the ED initial medical assessment. Secondary outcomes included analyses of relationships between predefined patient or clinical factors and the documentation of a clinical impression. RESULTS:During the study period, 16 431 adults attended one of four Monash Health EDs. After exclusions were applied, 432 patient records were randomly selected for analysis. Clinical impressions were absent in 23.4% of cases (95% CI 20%-28%, margin of error 3.9%). This was consistent across levels of clinician experience and triage categories, except for category 5 with higher rates of absent clinical impressions (67%; 95% CI 31%-91%). Differential diagnoses were documented in 39% of cases. High urgency patients had more clinical decision rules documented (4%; 95% CI 2%-7% vs. 14%; 95% CI 8%-23%). Inter-rater reliability for the primary outcome demonstrated strong agreement (κ = 0.91). CONCLUSION:Alarmingly, almost one-quarter of adult ED patients lacked a documented clinical impression in their initial medical assessment, irrespective of clinician experience and most triage categories. This gap should be addressed quickly to improve diagnostic decision making and protect patient safety.

OBJECTIVE:Paediatric resuscitations in the ED are high-pressure events in unpredictable settings. Traditionally, only cases with poor outcomes are reviewed to prevent future failures. Adopting a Safety-II mindset allows teams to reflect on both positive and negative experiences, enhancing care quality. The present study aimed to identify themes from staff feedback after paediatric resuscitations in the ED and describe system changes as a result. METHODS:A prospective quality improvement study was conducted over 31 months in a tertiary paediatric ED. Surveys were sent to clinical staff involved in paediatric resuscitations, requesting feedback on successes and suggestions for improvement. Responses were analysed using directed content analysis: initial coding using the London Protocol, a systems-focused review methodology, followed by inductive thematic analysis. Feedback was discussed in departmental Mortality and Morbidity and Quality and Safety Meetings, leading to systemic improvements. RESULTS:Eighty-nine paediatric resuscitation cases yielded 1320 specific feedback items from 256 staff members. Feedback covered all layers of the health system, with key themes focussed on the team, the environment and tasks/technology. Improvements included a transport checklist, a start-of-shift airway huddle and standardised medication preparation methods. CONCLUSIONS:Asynchronous feedback from staff involved in paediatric resuscitations identified positive and constructive themes across the health system. This feedback was successfully translated into a number of systems-focused actions to improve patient safety and care.

We followed up children with Bell’s palsy following completion of a randomised trial on the use of prednisolone. While the vast majority had complete recovery of facial function at 6 months, there were some children without full recovery of facial function at 12 month, regardless of prednisolone use.

AIM:To describe sources of advice and the recommendations given to parents/guardians prior to attending ED with their child. METHODS:This was a prospective observational study of patients presenting to two EDs of a multi-centre Victorian Health service in June 2016. Data collection involved surveying all parents/guardians attending paediatric ED during a 1-week period by trained research assistants. We determined the proportion of eligible respondents who sought advice before attending ED, the source of advice, and the type of advice provided. RESULTS:One thousand sixty-nine patients presented to ED over the 1-week period. There were 730 responses to the survey, of which 65% (477/730) had received a total of 620 recommendations prior to ED attendance. Seventy-six per cent (362/477) had received advice from a single source, 19% (90/477) had received advice from 2 sources, and 5% (25/477) from 3 or more sources. The most common sources of advice were general practice consultations (49%), friends/family (13.5%), and NURSE-ON-CALL (11%). Fifty-four per cent (335/620) of the recommendations were to attend ED immediately and 12% (77/620) were to attend if their child was getting worse. CONCLUSIONS:Most parents and guardians sought advice from a single source prior to attending an ED. The most common source of advice was consultation with a general practitioner and the most common recommendation was to attend ED immediately, or if their child's condition worsened.

OBJECTIVE:To describe the prevalence and severity of pain experienced by children with Bell's palsy over the first 6 months of illness and its association with the severity of facial paralysis.METHODS:This was a secondary analysis of data obtained in a phase III, triple-blinded, randomised, placebo-controlled trial of prednisolone for the treatment of Bell's palsy in children aged 6 months to <18 years conducted between 13 October 2015 and 23 August 2020 in Australia and New Zealand. Children were recruited within 72 hours of symptom onset and pain was assessed using a child-rated visual analogue scale (VAS), a child-rated Faces Pain Score-Revised (FPS-R) and/or a parent-rated VAS at baseline, and at 1, 3 and 6 months until recovered, and are reported combined across treatment groups.RESULTS:Data were available for 169 of the 187 children randomised from at least one study time point. Overall, 37% (62/169) of children reported any pain at least at one time point. The frequency of any pain reported using the child-rated VAS, child-rated FPS-R and parent-rated VAS was higher at the baseline assessment (30%, 23% and 27%, respectively) compared with 1-month (4%, 0% and 4%, respectively) and subsequent follow-up assessments. At all time points, the median pain score on all three scales was 0 (no pain).CONCLUSIONS:Pain in children with Bell's palsy was infrequent and primarily occurred early in the disease course and in more severe disease. The intensity of pain, if it occurs, is very low throughout the clinical course of disease.TRIAL REGISTRATION NUMBER:ACTRN12615000563561.

Background There is limited evidence on the use of facial nerve function grading scales in acute facial nerve paralysis in children. Objective To investigate the agreement between and the usability of the House-Brackmann and Sunnybrook scales in children with idiopathic facial paralysis (Bell's palsy) and to compare their ease of administration. Methods Data from a randomized controlled trial in children aged 6 months to <18 years with Bell's palsy was used. Children were recruited within 72 hours of symptom onset and assessed using the House-Brackmann and the Sunnybrook scales at baseline and at 1, 3, and 6 months until recovered. Agreement between the scales was assessed using the intraclass correlation coefficient (ICC) at each time point and using a Bland-Altman plot. Ease of administration was assessed using an 11-point Likert scale. Results Comparative data were available for 169 of the 187 children randomized. The ICC between the 2 scales across all time points was 0.92 (95% confidence interval [CI] 0.91-0.93), at baseline 0.37 (95% 0.25, 0.51), at 1 month 0.91 (95% CI 0.89-0.94), at 3 months 0.85 (95% CI 0.80-0.89), and at 6 months 0.96 (95% CI 0.95-0.97). The median score for the ease of administration for the House-Brackmann and Sunnybrook scales was 3 (interquartile range [IQR]: 1-5) and 7 (IQR: 4-8) respectively (P < .001, Wilcoxon signed-rank test). Conclusions There was excellent agreement between House-Brackmann and Sunnybrook scales, with poorer agreement at baseline. Clinicians found the House-Brackmann scale easier to administer. These findings suggest that both scales can be applied in children.

Franz Babl, David Herd, Meredith Borland, Amit Kochar, Ben Lawton, Jason Hort, Adam West, Shane George, Michael Zhang, Karthik Velusamy, Frank Sullivan, Ed Oakley, Andrew Davidson, Sandy Hopper, John Cheek, Robert Berkowitz, Stephen Hearps, Catherine Wilson, Amanda Williams, Hannah Elborough, Donna Legge, Mark Mackay, Katherine Lee, Stuart Dalziel Emergency Dept, Royal Children’s Hospital, Melbourne, Parkville, Australia; Clinical Sciences, Murdoch Children’s Research Institute (MCRI), Parkville, Australia; Dept of Paediatrics, University of Melbourne, Parkville, Australia; Dept of Critical Care, University of Melbourne, Parkville, Australia; Emergency Dept, Queensland Children’s Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia; Mater Research Institute, Brisbane, Australia; Emergency Dept, Perth Children’s Hospital, Perth, Australia; Div of Emergency Medicine and Paeds, University of Western Australia, Perth, Australia; Emergency Dept, Women’s and Children’s Hospital, Adelaide, Australia; Emergency Dept, Logan Hospital, Brisbane, Australia; Emergency Dept, The Children’s Hospital at Westmead, Sydney, Australia; Emergency Dept, Monash Medical Centre, Clayton, Australia; Dept of Emergency Medicine, Gold Coast University Hospital, Southport, Australia; School of Medicine and Menzies Health Institute, Griffith University, Southport, Australia; Child Health Research Centre, the University of Queensland, South Brisbane, Australia; Emergency Dept, John Hunter Hospital, Newcastle, Australia; Emergency Dept, Townsville Hospital, Townsville, Australia; James Cook University College of Medicine and Dentistry, Townsville, Australia; University of St Andrews, School of Medicine, Edinburgh, United Kingdom; North York General Hospital, University of Toronto, Toronto, Canada; Dept of Anaesthesia, Royal Children’s Hospital, Parkville, Australia; Dept of Otolaryngology, Royal Children’s Hospital, Parkville, Australia; Pharmacy Dept, Royal Children’s Hospital, Parkville, Australia; Dept of Neurology, Royal Children’s Hospital, Parkville, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, Parkville, Australia; Children’s Emergency Dept, Starship Children’s Hospital, Auckland, New Zealand; Dept of Surgery and Paediatrics, University of Auckland, Auckland, New Zealand. Background: Corticosteroids can be used to treat idiopathic facial paralysis (Bell’s palsy) in children, but their effectiveness is uncertain. Aim: To determine if prednisolone improves recovery of children with Bell’s palsy at 1 month. Method: Double-blind, placebo-controlled, randomised, trial of prednisolone in children presenting to ED with Bell’s palsy. Patients 6 months to <18 years, recruited <72 h after symptom onset, were randomly assigned to receive 10 days of treatment with oral prednisolone (1 mg/kg) or placebo. The primary outcome: complete recovery of facial function at 1 month on the House–Brackmann scale. Secondary outcomes: facial function, adverse events and pain to 6 months. Results: Between October 2015 to August 2020, 187 children were randomised (94 to prednisolone and 93 to placebo) and included in the intention-to-treat analysis (Table 1). At 1 month, the proportions of patients who had recovered facial function were 49% (n = 43/87) in the prednisolone group compared with 57% (n = 50/87) in the placebo group (risk difference −8.1%, 95% CI −22.8 to 6.7; adjusted odds ratio [aOR] 0.7, 95% CI 0.4–

Aims, Objectives and BackgroundCorticosteroids can be used to treat idiopathic facial paralysis (Bell’s palsy) in children, but their effectiveness is uncertain.AimsTo determine if prednisolone improves recovery of children with Bell’s palsy at one month.Method and DesignDouble-blind, placebo-controlled, randomised, trial of prednisolone in children presenting to ED with Bell’s palsy.1Patients 6 months to <18 years, recruited <72 hours after symptom onset, were randomly assigned to receive 10 days of treatment with oral prednisolone (1 mg/kg) or placebo. The primary outcome: complete recovery of facial function at 1 month on the House-Brackmann scale.2Secondary outcomes: facial function, adverse events and pain to 6 months.Results and ConclusionBetween October 2015 to August 2020, 187 children were randomised (94 to prednisolone and 93 to placebo) and included in the intention-to-treat analysis. At 1 month, the proportions of patients who had recovered facial function were 49% (n=43/87) in the prednisolone group compared with 57% (n=50/87) in the placebo group (risk difference -8.1%, 95% CI -22.8 to 6.7; adjusted odds ratio [aOR] 0.7, 95% CI 0.4 to 1.3). At 6 months these proportion were 99% (n=77/78) for prednisolone and 93% (n=76/82) for placebo respectively (risk difference 6.0%, 95% CI -0.1 to 12.2; aOR 3.0 95% CI 0.5 to 17.7) (figure 1). There were no serious adverse events and little evidence for group differences in secondary outcomes.Abstract 1396 Figure 1In children with Bell’s palsy the vast majority recover without treatment. The study does not provide evidence that early treatment with prednisolone improves complete recovery.ReferencesSullivan F, Swan I, Donna P, Morrison J, Smith B, McKinstry B,et al. Early treatment with prednisolone or acyclovir in bell’s palsy.N Eng J Med2007;357(16):1598–607.House JW, Brackmann DE. Facial nerve grading system.Otolaryngol Head Neck Surg. 1985;93(2):146–7.

BACKGROUND AND OBJECTIVES:Corticosteroids are used to treat the early stages of idiopathic facial paralysis (Bell palsy) in children, but their effectiveness is uncertain. We set out to determine whether prednisolone improves the proportion of children with Bell palsy with complete recovery at 1 month. METHODS:We conducted a double-blind, placebo-controlled, randomized trial of prednisolone in children presenting to emergency departments with Bell palsy. Patients aged 6 months to younger than 18 years were recruited within 72 hours after the symptom onset and were randomly assigned to receive 10 days of treatment with oral prednisolone (approximately 1 mg/kg) or placebo. The primary outcome was complete recovery of facial function at 1 month rated on the House-Brackmann scale. Secondary outcomes included facial function, adverse events, and pain up to 6 months. Target recruitment was n = 540 (270 per group). RESULTS:Between October 13, 2015, and August 23, 2020, 187 children were randomized (94 to prednisolone and 93 to placebo) and included in the intention-to-treat analysis. At 1 month, the proportions of patients who had recovered facial function were 49% (n = 43/87) in the prednisolone group compared with 57% (n = 50/87) in the placebo group (risk difference -8.1%, 95% CI -22.8 to 6.7; adjusted odds ratio [aOR] 0.7, 95% CI 0.4 to 1.3). At 3 months, these proportions were 90% (n = 71/79) for the prednisolone group vs 85% (n = 72/85) for the placebo group (risk difference 5.2%, 95% CI -5.0 to 15.3; aOR 1.2, 95% CI 0.4 to 3.0) and, at 6 months, 99% (n = 77/78) and 93% (n = 76/82), respectively (risk difference 6.0%, 95% CI -0.1 to 12.2; aOR 3.0, 95% CI 0.5 to 17.7). There were no serious adverse events and little evidence for group differences in secondary outcomes. DISCUSSION:In children with Bell palsy, the vast majority recover without treatment. This study, although underpowered, does not provide evidence that early treatment with prednisolone improves complete recovery. TRIAL REGISTRATION INFORMATION:Registered with the Australian New Zealand Clinical Trials Registry ACTRN12615000563561, registered June 1, 2015. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368505&isReview=true. CLASSIFICATION OF EVIDENCE:This study provides Class I evidence that for children with Bell palsy, prednisolone does not significantly change recovery of complete facial function at 1 month. However, this study lacked the precision to exclude an important harm or benefit from prednisolone.

Background and Objectives Corticosteroids are used to treat the early stages of idiopathic facial paralysis (Bell palsy) in children, but their effectiveness is uncertain. We set out to determine whether prednisolone improves the proportion of children with Bell palsy with complete recovery at 1 month. Methods We conducted a double-blind, placebo-controlled, randomized trial of prednisolone in children presenting to emergency departments with Bell palsy. Patients aged 6 months to younger than 18 years were recruited within 72 hours after the symptom onset and were randomly assigned to receive 10 days of treatment with oral prednisolone (approximately 1 mg/kg) or placebo. The primary outcome was complete recovery of facial function at 1 month rated on the House-Brackmann scale. Secondary outcomes included facial function, adverse events, and pain up to 6 months. Target recruitment was n = 540 (270 per group). Results Between October 13, 2015, and August 23, 2020, 187 children were randomized (94 to prednisolone and 93 to placebo) and included in the intention-to-treat analysis. At 1 month, the proportions of patients who had recovered facial function were 49% (n = 43/87) in the prednisolone group compared with 57% (n = 50/87) in the placebo group (risk difference −8.1%, 95% CI −22.8 to 6.7; adjusted odds ratio [aOR] 0.7, 95% CI 0.4 to 1.3). At 3 months, these proportions were 90% (n = 71/79) for the prednisolone group vs 85% (n = 72/85) for the placebo group (risk difference 5.2%, 95% CI −5.0 to 15.3; aOR 1.2, 95% CI 0.4 to 3.0) and, at 6 months, 99% (n = 77/78) and 93% (n = 76/82), respectively (risk difference 6.0%, 95% CI −0.1 to 12.2; aOR 3.0, 95% CI 0.5 to 17.7). There were no serious adverse events and little evidence for group differences in secondary outcomes. Discussion In children with Bell palsy, the vast majority recover without treatment. This study, although underpowered, does not provide evidence that early treatment with prednisolone improves complete recovery. Trial Registration Information Registered with the Australian New Zealand Clinical Trials Registry ACTRN12615000563561, registered June 1, 2015. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368505&isReview=true. Classification of Evidence This study provides Class I evidence that for children with Bell palsy, prednisolone does not significantly change recovery of complete facial function at 1 month. However, this study lacked the precision to exclude an important harm or benefit from prednisolone.

Background Quality improvement systems are needed to overcome the ‘Quality Gap’ – difference between evidence-based guidelines and the care delivered. While there are a large array of potential quality assurance measures exists in the Paediatric Emergency Department, parent’s/carer’s perception of these is unknown. This study aimed to identify what ‘quality of care’ means to parents/carers of Paediatric Emergency Department (PED) patients, further determine which aspects of these are most important to them. Also, to identify which of the existing PED quality measures are most important to parents/carers, and their preferred method of providing feedback. Methods A Modified Rand-Delphi study was performed with parents/carers as the expert group and consensus was obtained from them via three web-based surveys. All parents/carers of children attending a tertiary paediatric hospital during six-week in winter were eligible– no exclusions. Quality measures scoring at least 7 on a 9-point Likert scale during the final survey were considered “very important”, while those scoring at least an 8 were considered “extremely important”. Results One hundred four parents/carers responded from a total of 1095 participants. Parents/carers generated 527 free text entries, to the initial survey on what ‘quality of care’ means. These were mapped to 48 quality measure which they ranked on subsequent surveys. Eighteen quality measures were considered very important by at least 90% of respondents. Of these, six were considered extremely important by at least 70% of respondents: ‘Thorough medical assessment’ (84%); ‘A triage system’ (84%); ‘Experienced and knowledgeable staff that are skilled in paediatrics’ (77%); ‘Resources and equipment available to provide care’ (72%); and ‘Clear follow up plans and reviews that are communicated and scheduled’ (72%). Parents/carers considered existing quality measures as important with ‘timely treatment of a critical condition’ as the most important. Most participants preferred to provide anonymous feedback ( N = 69, 66%), online ( N = 77, 72%) after discharge ( N = 82, 70%). Conclusion We have elicited what ‘quality of care’ means to parents/carers, and which aspects are most important to them. Parents/carers consider commonly used PED quality measure as very important. However, they are less important than outcomes generated by themselves. Further parents/carers in this study preferred to provide feedback that was anonymous and electronically distributed after they leave the ED.

Most children with peripheral facial palsy will not have a cause identified. Although leukemia can cause facial nerve palsy, the magnitude of the risk is unknown and recommendations for investigations are variable. We are currently conducting a randomized, placebo-controlled trial of prednisolone for the treatment of Bell's palsy in children within the Paediatric Research in Emergency Departments International Collaborative emergency research network. In the course of the assessment for eligibility of the trial, from 644 acute-onset facial palsy presentations we identified 5 children with previously undiagnosed leukemia. We estimate the rate of leukemia in children with acute-onset facial palsy who present to emergency departments to be 0.6% (95% confidence interval 0.2% to 1.6%). In accordance with these cases, we suggest consideration of a screening CBC count for acute-onset peripheral facial palsy presentations in children before initiation of corticosteroid treatment.

Objective Victorian ED data show increased presentations for anxiety and depression in children. We aimed to determine parent-reported factors contributing to these presentations. Methods Qualitative study with parents of children and young people aged 0-17 years who attended one of four EDs across Victoria between October 2017 and September 2018 and received a primary diagnosis of anxiety or depression (excluding self-harm or suicide attempt). Eligible parents completed semi-structured phone interviews, which were audio-recorded and transcribed. Transcripts were coded and qualitatively analysed using thematic analysis. Results Seventy parents completed interviews. The average age of children and young people was 14 years (standard deviation 2.4) and 63% (n = 44) identified as female. Thirty (43%) children received a primary diagnosis of depression, compared to 40 (57%) children who received a primary diagnosis of anxiety. The majority of respondents were mothers (n = 59; 84%). Key themes as to why families presented to EDs included: listening to trusted professionals, desperation, a feeling of no alternative, respecting their child's need to feel safe and to rule out a potentially serious medical condition. Conclusions Parents bring their children to the ED for many reasons. Policy makers, managers and clinicians should work with parents to develop alternative approaches that provide families with community-based support, particularly for younger children and after hours, in order to provide an appropriate source of care for children and young people with anxiety and depression.

To determine if changes to community-based services have effected paediatric ED attendances for mental health issues and neonates during the COVID-19 pandemic. Analysis of total presentations, presentations with a mental health diagnoses and presentation of neonates during the early stages of the pandemic compared with the previous year for four Victorian hospitals. There was a 47.2% decrease in total presentations compared with 2019, with a 35% increase in mental health diagnoses and a 2% increase in neonatal presentations. Vulnerable paediatric patients are seeking care elsewhere during the pandemic because of the closure of community services.

Victorian ED data show increased presentations for anxiety and depression in children. We aimed to determine parent-reported factors contributing to these presentations. Qualitative study with parents of children and young people aged 0–17 years who attended one of four EDs across Victoria between October 2017 and September 2018 and received a primary diagnosis of anxiety or depression (excluding self-harm or suicide attempt). Eligible parents completed semi-structured phone interviews, which were audio-recorded and transcribed. Transcripts were coded and qualitatively analysed using thematic analysis. Seventy parents completed interviews. The average age of children and young people was 14 years (standard deviation 2.4) and 63% ( n = 44) identified as female. Thirty (43%) children received a primary diagnosis of depression, compared to 40 (57%) children who received a primary diagnosis of anxiety. The majority of respondents were mothers ( n = 59; 84%). Key themes as to why families presented to EDs included: listening to trusted professionals, desperation, a feeling of no alternative, respecting their child's need to feel safe and to rule out a potentially serious medical condition. Parents bring their children to the ED for many reasons. Policy makers, managers and clinicians should work with parents to develop alternative approaches that provide families with community-based support, particularly for younger children and after hours, in order to provide an appropriate source of care for children and young people with anxiety and depression.

Aim The number of children and young people presenting to emergency departments (EDs) with anxiety and depression is increasing. We aimed to determine parent perspectives on: (i) barriers to accessing non-ED mental health services; and (ii) improving access in the paediatric mental health service system. Methods Qualitative study with parents of children and young people aged 0-19 years who attended one of four EDs across Victoria between October 2017 and September 2018 and received a primary diagnosis of anxiety or depression. Exclusion criteria: child or young person without a parent/guardian, or presented with self-harm or suicide attempt. Eligible participants completed semi-structured phone interviews. Interviews were recorded and transcripts were coded and analysed using content analysis. Results A total of 72 parents completed interviews. The average child age was 14 years (standard deviation 2.5) and two thirds identified as female (64%). A total of 57% of children and young people presented with a primary diagnosis of anxiety. Parents reported barriers in accessing care including: service shortages and inaccessibility, underresourced schools, lack of clinician mental health expertise, lack of child-clinician rapport, inconsistent care, financial constraints, lack of mental health awareness among parents, and stigma. Parents want expanded and improved access to services, more respite and support services, supportive schools, and improved mental health education for parents. Conclusions Parents of children and young people attending the ED for anxiety and depression are generally dissatisfied with services for child mental health. Solutions that enable parents to better care for their child in the community are needed to improve care.

OBJECTIVE:To determine if changes to community-based services have effected paediatric ED attendances for mental health issues and neonates during the COVID-19 pandemic.METHODS:Analysis of total presentations, presentations with a mental health diagnoses and presentation of neonates during the early stages of the pandemic compared with the previous year for four Victorian hospitals.RESULTS:There was a 47.2% decrease in total presentations compared with 2019, with a 35% increase in mental health diagnoses and a 2% increase in neonatal presentations.CONCLUSION:Vulnerable paediatric patients are seeking care elsewhere during the pandemic because of the closure of community services.

OBJECTIVES To evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput. DESIGN Randomised, multicentre clinical trial. SETTING Five emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit. PARTICIPANTS 88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site. INTERVENTIONS Physicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018. MAIN OUTCOME MEASURES Physicians' productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians' productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done. RESULTS Data were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians' productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub-acute/fast track regions. No significant harm involving scribes was reported. The cost-benefit analysis based on productivity and throughput gains showed a favourable financial position with use of scribes. CONCLUSIONS Scribes improved emergency physicians' productivity, particularly during primary consultations, and decreased patients' length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia's.

BACKGROUND:Nasogastric tube insertion is a common but distressing procedure in young children. We aimed to compare the efficacy of topical local anaesthetic and vasoconstrictor nasal spray with placebo for distress related to nasogastric tube insertion. METHODS:We did a prospective, randomised, controlled, double-blind, superiority trial in a single tertiary paediatric emergency department in Australia. Eligible participants were children aged 6 months to 5 years who were planned to have a nasogastric tube inserted as part of their emergency department treatment. Patients were assigned using computer-generated block randomisation to receive lidocaine and phenylephrine nasal spray (10 mg lidocaine and 1 mg phenylephrine for children weighing 6-12 kg; 20 mg lidocaine and 2 mg phenylephrine for children weighing >12 kg), or 0·9% sodium chloride placebo nasal spray, before nasogastric insertion. Guardians, observers, and proceduralists were all masked to the intervention. The primary outcome was procedure-related distress, measured using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale during the final attempt at nasogastric tube insertion. All patients were included in the primary analysis (intention-to-treat). FLACC scores were compared using the Wilcoxon rank-sum test, and categorical outcomes were compared using χ2 or Fisher's exact tests as appropriate. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000092695. FINDINGS:Between July 30, 2014, and Aug 17, 2017, 107 children in a convenience sample were randomly assigned to receive lidocaine and phenylephrine nasal spray (n=54) or placebo (n=53). Seven children did not receive study medication (six no longer required nasogastric tube insertion and one withdrew consent). 50 children received each intervention; all were included in the analysis. There was no difference in median FLACC score at time of nasogastric tube insertion (9 [IQR 7-10] for lidocaine and phenylephrine vs 9 [IQR 8-10] for placebo; median difference between groups -1, 95% CI -2·7 to 0·7, p=0·21). Adverse effects of the spray or nasogastric tube insertion (most commonly vomiting and gagging) occurred in 14 (28%) of those who received lidocaine and phenylephrine and 21 (42%) of those who received placebo. INTERPRETATION:Lidocaine and phenylephrine nasal spray does not reduce procedure-related distress associated with nasogastric tube insertion in young children compared with placebo. Further research addressing distress associated with nasogastric tube insertion in young children is needed. FUNDING:Monash Health Senior Medical Staff Association, Australasian College for Emergency Medicine, Emergency Medicine Research Foundation.