Canadian Pediatric Emergency Departments Research Articles

Exploring Cannabis-Associated Presentations to Canadian Pediatric Emergency Departments: A Cross-Sectional Study

Exploring Cannabis-Associated Presentations to Canadian Pediatric Emergency Departments: A Cross-Sectional Study

32 A randomized controlled trial of virtual reality-based distraction for intravenous cannulation-related distress in children

Abstract Background Children commonly experience under-treated pain and distress related to medical procedures, such as intravenous insertions (IVI), leading to both short- and long-term negative consequences for patients and their caregivers. Virtual reality (VR) has emerged as a promising tool to ameliorate procedure-related distress in the paediatric healthcare setting; however, existing evidence has largely employed custom VR software, which can be expensive and inaccessible. As such, we aimed to characterize whether commercially available VR applications are effective in reducing children’s procedure-related distress. Objectives To assess the effectiveness of commercially available VR-based distraction when added to standard of care (SOC, which included topical anesthetic cream), in reducing distress for children undergoing IVI in the paediatric emergency department (PED). Design/Methods Children aged 6 to 17 years requiring IVI in a Canadian PED were recruited for a two-arm randomized controlled trial. The primary outcome was child distress, measured using the Observational Scale of Behavioural Distress – Revised (OSBD-R, score range 0-23.5). Secondary outcomes included child pain intensity (measured with the Faces Pain Scale-Revised, score range 0-10) and caregiver anxiety [measured by the State-Trait Anxiety Inventory-State (STAI-S), score range 20-80] during the procedure. Trial registration number: NCT04291404C. Results 82 children and their caregivers were included. 41 children received VR distraction in addition to SOC (mean age 10.8 years, SD 3.0), while 41 children received SOC alone (mean age 11.3 years, SD 2.8). There was no significant difference between OSBD-R-measured distress in the VR arm (mean 1.05, SD 1.52) compared to the SOC arm (mean 0.71, SD 1.40) (p = 0.08). There was no significant reduction in procedural pain intensity in the VR group (mean 4.20,SD 3.10) compared to the SOC group (mean 4.10, SD 3.20) (p = 0.85). There was no difference in caregiver STAI-S score immediately following IVI in the VR arm (mean 32.3, SD 11.3) versus the SOC arm (mean 32.3, SD 11.9) (p = 0.86). Conclusion VR distraction therapy employing commercially available software was not associated with reduction in procedural distress or pain, above that provided with SOC in the PED, for children undergoing IVI. This result highlights the need for more accessible custom VR distraction software, created to meet the unique psychological needs of children undergoing medical procedures. Further study is needed to directly compare custom versus commercially available VR software for this application.

31 Impact of the amount of intravenous glucose administration on hospitalization for acute gastroenteritis in a paediatric emergency department

Abstract Background In case of failure of oral rehydration, children with acute gastroenteritis can be hydrated using intravenous (IV) solution. The choice of the intravenous solution itself (solutions containing dextrose versus crystalloids alone) and the glucose quantities to administer are not well established. Objectives The main objective of this study was to evaluate the impact of the amount of intravenous glucose provided to children treated for acute gastroenteritis on hospitalizations. Other objectives were to evaluate practice variation regarding the amount of glucose and liquid provided for IV rehydration in a paediatric emergency department (ED). Design/Methods We conducted a retrospective cohort study from 2019-2022 in a Canadian paediatric ED. We included children with acute gastroenteritis undergoing IV rehydration. Patient with hypoglycemia, metabolic disease or diabetes were excluded. The IV glucose administered during the initial four hours of rehydration was quantified. The primary outcome was hospitalization and return visit in the following seven days was a secondary outcome. 10% of the charts were evaluated in duplicate to assess inter-rater reliability. We examined glucose distribution at one and four hours, and utilized multiple logistic regression to relate glucose amounts with hospitalization and second visit, accounting for age, weight, bicarbonate levels, ondansetron use, and amount of liquid infused. It was estimated that the evaluation of 250 cases would have at least 50 admissions. Results Among 6,939 children evaluated for potential acute gastroenteritis, 250 met our inclusion/exclusion criteria. All variables included in the analysis had excellent inter-rater reliability. Notable variations existed in glucose quantities provided, both at one hour (first quartile: 87 mg/Kg; third quartile: 294 mg/Kg) and four hours (first quartile: 681 mg/Kg; third quartile: 1174 mg/kg) of rehydration. Multiple logistic regression showed a greater hospitalization risk with smaller amount of glucose administered during the initial hour (OR for each 100mg/kg increment: 0.60; 95%CI: 0.42-0.84) and four hours (OR: 0.76; 95%CI: 0.63-0.91) of rehydration. Moreover, children who received more dextrose during the first hour of rehydration were at lower risk of return visit (OR for each 100mg/kg increment: 0.52; 95%CI: 0.35-0.78), as well as during the first four hours (OR for each 100 mg/kg increment: 0.83; 95%CI: 0.73-0.94). Conclusion There was a wide practice variation in intravenous glucose provided to children with acute gastroenteritis. In this population, higher intravenous glucose amount was associated to a lower risk of hospitalization and lower risk of return visit.

Key Considerations in Integrating a Peer Support Model Within Psychiatric Emergency Services at a Canadian Pediatric Emergency Department: A Qualitative Study.

Difficulties accessing primary care and community-based mental health supports has contributed toyouth (aged < 18years) with mental health concerns presenting to Emergency Departments (EDs). Peer support services in community-based mental health settings areassociated with improved outcomes; research exploring this in pediatric EDs is lacking. Determinefeasibility and acceptability of integrating peer support services into a pediatric ED. 13 peer support workers (PSWs) and 30 mental health providers andstakeholders participated in interviews or focus groups. Using codebookthematic analysis,recommendations for integrationwere identified. Key recommendations were:clear conceptualization of youth and family peer support, effective communication pathways between the multidisciplinary team and PSWs, provision of training for ED staff to ensure workplace readiness for peer support, and consistent support for PSWs. Integration of peer support into pediatric EDs offers a feasible andacceptable way to support youth experiencing mental health crises.

Research capacity and limitations in Canadian paediatric emergency departments: An observational study on biomarker discovery

Research capacity and limitations in Canadian paediatric emergency departments: An observational study on biomarker discovery

Prevalence of pain-related presentations in Canadian pediatric emergency departments.

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 (< 18years) were eligible for inclusion. Data were extracted from administrative sources with one week of consecutive patients included every 3months 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% were male. 58.8% of children were found to have pain as a component of their triage presentation. Of those with pain (n = 4237), 24.1% had a pain score documented and 13.8% had analgesia provided at triage. Location of pain (n = 4523) was predominantly in the head (38.0%), extremities (27.8%), and abdomen (22.8%). Primary organ systems most affected (n = 4237) included the musculoskeletal (31.1%), gastrointestinal (18.3%), and cutaneous (including lacerations) (14.4%) systems. In this study, pain was identified in almost 60% of all pediatric emergency department presentations at the time of triage. Suboptimal documentation of pain scores and provision of analgesia at triage were found for children with pain. These results support early assessment and implementation of pain management strategies at triage. Results can also focus further research efforts to the management of the most commonly presenting types of pediatric pain.

A national survey of children's experiences and needs when attending Canadian pediatric emergency departments.

Optimizing a child's emergency department (ED) experience positively impacts their memories and future healthcare interactions. Our objectives were to describe children's perspectives of their needs and experiences during their ED visit and relate this to their understanding of their condition. 514 children, aged 7-17 years, and their caregivers presenting to 10 Canadian pediatric EDs completed a descriptive cross-sectional survey from 2018-2020. Median child age was 12.0 years (IQR 9.0-14.0); 56.5% (290/513) were female. 78.8% (398/505) reported adequate privacy during healthcare conversations and 78.3% (395/504) during examination. 69.5% (348/501) understood their diagnosis, 89.4% (355/397) the rationale for performed tests, and 67.2% (338/503) their treatment plan. Children felt well taken care of by nurses (90.9%, 457/503) and doctors (90.8%, 444/489). Overall, 94.8% (475/501) of children were happy with their ED visit. Predictors of a child better understanding their diagnosis included doctors talking directly to them (OR 2.21 [1.15, 4.28]), having someone answer questions and worries (OR 2.51 [1.26, 5.01]), and older age (OR 1.08 [1.01, 1.16]). Direct communication with a doctor (OR 2.08 [1.09, 3.99]) was associated with children better understanding their treatment, while greater fear/ 'being scared' at baseline (OR 0.59 [0.39, 0.89]) or at discharge (OR 0.46 [0.22, 0.96]) had the opposite effect. While almost all children felt well taken care of and were happy with their visit, close to 1/3 did not understand their diagnosis or its management. Children's reported satisfaction in the ED should not be equated with understanding of their medical condition. Further, caution should be employed in using caregiver satisfaction as a proxy for children's satisfaction with their ED visit, as caregiver satisfaction is highly linked to having their own needs being met.

Non-suicidal self-injury at a Canadian paediatric emergency department.

Our primary objective was to determine agreement between non-suicidal self-injury recorded at triage and during subsequent mental health assessment. The secondary objective was to describe patients who reported non-suicidal self-injury. This is a health records review of patients aged 12-18years who had an Emergency Mental Health Triage form on their health record from an ED visit June 1, 2017-May 31, 2018. We excluded patients with diagnoses of autism spectrum disorder or schizophrenia. We abstracted data from the Mental Health Triage form, Emergency Mental Health and Addictions Service Assessment forms and Assessment of Suicide and Risk Inventory. We calculated Cohen's Kappa coefficient, sensitivity, and negative predictive value to describe the extent to which the forms agreed and the performance of triage for identifying non-suicidal self-injury. We compared the cohort who reported non-suicidal self-injury with those who did not, using t-tests, Wilcoxon rank-sum tests, and chi-square tests. We screened 955 ED visits and included 914 ED visits where 558 (58.4%) reported a history of non-suicidal self-injury. There were significantly more females in the group reporting non-suicidal self-injury (82.1%, n = 458) compared to the group not reporting non-suicidal self-injury (45.8%, n = 163). Patients reporting non-suicidal self-injury did so in triage and detailed Mental Health Assessment 64.7% of the time (Cohen's Kappa Coefficient 0.6); triage had sensitivity of 71.5% (95% CI 67.3-75.4) and negative predictive value of 71.2% (95% CI 68.2-74.0). Cutting was the most common method of non-suicidal self-injury (80.3%). Screening at triage was moderately effective in identifying non-suicidal self-injury compared to a detailed assessment by a specialised mental health team. More than half of children and adolescents with a mental health-related concern in our ED reported a history of non-suicidal self-injury, most of which were female. This symptom is important for delineating patients' coping strategies.

Optimal Volume of Moderate-to-Vigorous Physical Activity Postconcussion in Children and Adolescents

Determining the optimal volume of early moderate-to-vigorous-intensity physical activity (MVPA) after concussion and its association with subsequent symptom burden is important for early postinjury management recommendations. To investigate the association between cumulative MVPA (cMVPA) over 2 weeks and subsequent symptom burden at 1 week, 2 weeks, and 4 weeks postinjury in children and examine the association between cMVPA and odds of persisting symptoms after concussion (PSAC) at 2 weeks and 4 weeks postinjury. This multicenter cohort study used data from a randomized clinical trial that was conducted from March 2017 to December 2019 at 3 Canadian pediatric emergency departments in participants aged 10.00 to 17.99 years with acute concussion of less than 48 hours. Data were analyzed from July 2022 to December 2023. cMVPA postinjury was measured with accelerometers worn on the waist for 24 hours per day for 13 days postinjury, with measurements deemed valid if participants had 4 or more days of accelerometer data and 3 or fewer consecutive days of missing data. cMVPA at 1 week and 2 weeks postinjury was defined as cMVPA for 7 days and 13 days postinjury, respectively. Multiple imputations were carried out on missing MVPA days. Self-reported postconcussion symptom burden at 1 week, 2 weeks, and 4 weeks postinjury using the Health and Behavior Inventory (HBI). PSAC was defined as reliable change on the HBI. A linear mixed-effect model was used for symptom burden at 1 week, 2 weeks, and 4 weeks postinjury with a time × cMVPA interaction. Logistic regressions assessed the association between cMVPA and PSAC. All models were adjusted for prognostically important variables. In this study, 267 of 456 children (119 [44.6%] female; median [IQR] age, 12.9 [11.5 to 14.4] years) were included in the analysis. Participants with greater cMVPA had significantly lower HBI scores at 1 week (75th percentile [258.5 minutes] vs 25th percentile [90.0 minutes]; difference, -5.45 [95% CI, -7.67 to -3.24]) and 2 weeks postinjury (75th percentile [565.0 minutes] vs 25th percentile [237.0 minutes]; difference, -2.85 [95% CI, -4.74 to -0.97]) but not at 4 weeks postinjury (75th percentile [565.0 minutes] vs 25th percentile [237.0 minutes]; difference, -1.24 [95% CI, -3.13 to 0.64]) (P = .20). Symptom burden was not lower beyond the 75th percentile for cMVPA at 1 week or 2 weeks postinjury (1 week, 259 minutes; 2 weeks, 565 minutes) of cMVPA. The odds ratio for the association between 75th and 25th percentile of cMVPA and PSAC was 0.48 (95% CI, 0.24 to 0.94) at 2 weeks. In children and adolescents with acute concussion, 259 minutes of cMVPA during the first week postinjury and 565 minutes of cMVPA during the second week postinjury were associated with lower symptom burden at 1 week and 2 weeks postinjury. At 2 weeks postinjury, higher cMVPA volume was associated with 48% reduced odds of PSAC compared with lower cMVPA volume.

Post–COVID-19 Condition in Children 6 and 12 Months After Infection

There is a need to understand the long-term outcomes among children infected with SARS-CoV-2. To quantify the prevalence of post-COVID-19 condition (PCC) among children tested for SARS-CoV-2 infection in pediatric emergency departments (EDs). Multicenter, prospective cohort study at 14 Canadian tertiary pediatric EDs that are members of the Pediatric Emergency Research Canada network with 90-day, 6-month, and 12-month follow-up. Participants were children younger than 18 years who were tested for SARS-CoV-2 infection between August 2020 and February 2022. Data were analyzed from May to November 2023. The presence of SARS-CoV-2 infection at or within 14 days of the index ED visit. Presence of symptoms and QoL reductions that meet the PCC definition. This includes any symptom with onset within 3 months of infection that is ongoing at the time of follow-up and affects everyday functioning. The outcome was quantified at 6 and 12 months following the index ED visit. Among the 5147 children at 6 months (1152 with SARS-CoV-2 positive tests and 3995 with negative tests) and 5563 children at 12 months (1192 with SARS-CoV-2 positive tests and 4371 with negative tests) who had sufficient data regarding the primary outcome to enable PCC classification, the median (IQR) age was 2.0 (0.9-5.0) years, and 2956 of 5563 (53.1%) were male. At 6-month follow-up, symptoms and QoL changes consistent with the PCC definition were present in 6 of 1152 children with positive SARS-CoV-2 tests (0.52%) and 4 of 3995 children with negative SARS-CoV-2 tests (0.10%; absolute risk difference, 0.42%; 95% CI, 0.02% to 0.94%). The PCC definition was met at 12 months by 8 of 1192 children with positive SARS-CoV-2 tests (0.67%) and 7 of 4371 children with negative SARS-CoV-2 tests (0.16%; absolute risk difference, 0.51%; 95% CI, 0.06 to 1.08%). At 12 months, the median (IQR) PedsQL Generic Core Scale scores were 98.4 (90.0-100) among children with positive SARS-CoV-2 tests and 98.8 (91.7-100) among children with negative SARS-CoV-2 tests (difference, -0.3; 95% CI, -1.5 to 0.8; P = .56). Among the 8 children with SARS-CoV-2 positive tests and PCC at 12-month follow-up, children reported respiratory (7 of 8 patients [88%]), systemic (3 of 8 patients [38%]), and neurologic (1 of 8 patients [13%]) symptoms. In this cohort study of children tested for SARS-CoV-2 infection in Canadian pediatric EDs, although children infected with SARS-CoV-2 reported increased chronic symptoms, few of these children developed PCC, and overall QoL did not differ from children with negative SARS-CoV-2 tests.

Family caregivers' emotional and communication needs in Canadian pediatric emergency departments.

To 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. Electronic 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. This 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. Approximately 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.

Dynamic Relations Between Psychological Resilience and Post-Concussion Symptoms in Children With Mild Traumatic Brain Injury Versus Orthopedic Injury: An A-CAP Study.

Higher psychological resilience is correlated with less severe post-concussion symptoms (PCS) after mild traumatic brain injury (mTBI) in children, but the directional nature of this relationship remains uncertain. Although traditionally regarded as a stable, trait-like construct, resilience may be malleable and potentially influenced by mTBI and post-concussive symptoms. The current study sought to examine the stability of resilience, elucidate the dynamic nature of the resilience-PCS relation, and determine whether resilience-symptom associations are specific to mTBI or applicable to traumatic injury in general. Participants were children aged 8-16.99 years with either mTBI (n = 633) or orthopedic injury (OI; n = 334) recruited to participate in a prospective cohort study after presenting acutely to five Canadian pediatric emergency departments (EDs). Symptoms and psychological resilience were assessed at 1 week, 3 months, and 6 months post-injury. Group differences in resilience over time were examined using a mixed linear model, and associations between resilience and symptoms over time were examined using random intercepts cross-lagged panel modeling (RI-CLPM). The mTBI group reported significantly lower resilience than the OI group, but the difference was significantly larger 1 week post-injury (d = 0.50) than at 3 months (d = 0.08) and 6 months (d = 0.10). Cross-lagged panel models indicated that resilience had both stable and dynamic aspects, and both affected and was affected by PCS, although their association varied by time post-injury, symptom measure, and reporter (parent vs. child). Higher parent-reported cognitive symptom severity at 1 week was significantly associated with higher resilience at 3 months (β = 0.23, p = 0.001). Higher resilience at 3 months was associated with lower levels of parent-reported somatic symptom severity (β = -0.14, p = 0.004) and fewer total symptoms (β = -0.135, p = 0.029) at 6 months. Higher resilience at 3 months was associated with fewer child-reported symptoms at 6 months (β = -0.11, p = 0.030) and, reciprocally, fewer child-reported symptoms at 3 months were associated with higher resilience at 6 months (β = -0.22, p = 0.001). Notably, injury group was not a significant moderator in cross-lagged models, suggesting that resilience-symptom associations are not specific to mTBI. Psychological resilience and symptoms have bidirectional relationships after injury. Interventions designed to foster resilience have the potential to promote recovery after mTBI specifically and injury more generally.

Nitrous oxide use in Canadian pediatric emergency departments: a survey of physician's knowledge, attitudes, and practices.

Nitrous oxide (N2O) is an inhaled analgesic/ anxiolytic gas with evidence supporting its safety and efficacy for distressing procedures in children. Despite this, its use is not consistent across Canadian pediatric emergency departments (EDs). We aimed to characterize a) physicians' knowledge and practices with N2O and b) site-specific N2O protocols in Canadian pediatric EDs to help optimize its use nationally. This cross-sectional survey was distributed to physician members of Pediatric Emergency Research Canada (PERC) in early 2021. Survey items addressed practice patterns, clinician comfort, and perceived barriers/ facilitators to use. Further, a representative from each ED completed a site-specific inventory of N2O policies and procedures. N2O was available in 40.0% of 15 pediatric EDs, with 83.3% of these sites having written policies in place. Of 230 distributed surveys, 67.8% were completed with mean (SD) attending experience of 14.7 (8.6) years and 70.1% having pediatric emergency subspecialty training. Of the 156 respondents, 48.7% used N2O in their clinical practice. The most common indications for use were digit fracture/ dislocation reduction (69.7%), wound closure (60.5%), and incision & drainage (59.2%). Commonly perceived facilitators were N2O equipment availability (73.0% of 156) and previous clinical experience (71.7% of 156). Of the 51.3% of physicians who reported not using N2O, 93.7% did not have availability at their site; importantly, the majority indicated a desire to acquire access. They identified concerns about ventilation/ scavenging systems (71.2% of 80) and unfamiliarity with equipment (52.5% of 80) as the most common barriers to use. Despite evidence to support its use, only half of Canadian pediatric ED physicians surveyed use N2O in their clinical practice for treating procedure-related pain and distress. Increased availability of N2O equipment, protocols, and training may improve clinicians' abilities to better manage pediatric acute pain and distress in the ED.

Antibiotic Prescribing Practices for Urinary Tract Infection in a Pediatric Emergency Department: Is This a Problem Worth Cefix-ing?

Pediatric urinary tract infection (UTI) is associated with diagnostic and therapeutic challenges. To determine the least-broad-spectrum oral antibiotic that would cover 80% of pathogens from lower (afebrile) and upper (febrile) UTIs in a Canadian pediatric emergency department (ED). This retrospective case series involved children discharged from the ED between September 2020 and February 2021 with a diagnosis of UTI and collection of a sample for urinalysis that had growth on culture. Of 188 patients who met the inclusion criteria, 184 (97.9%) were discharged on antibiotics. Culture results indicated a UTI in 170 cases (92.4% of those discharged on antibiotics). The 95 urinary isolates from lower UTIs were susceptible to cephalexin (n = 81, 85.3%), cefixime (n = 78, 82.1%), nitrofurantoin (n = 76, 80.0%), trimethoprim-sulfamethoxazole (TMP-SMX) (n = 64, 67.4%), and amoxicillin (n = 55, 57.9%). The 75 urinary isolates from upper UTIs were susceptible to cefixime (n = 71, 94.7%), TMP-SMX (n = 57, 76.0%), and amoxicillin (n = 48, 64.0%). The mean prescribed duration of antibiotic therapy was 8.3 days for patients with a lower UTI and 9.1 days for those with an upper UTI (mean difference 0.80 days, 95% confidence interval 0.05-1.54). Empiric treatment with cephalexin or nitrofurantoin would have been successful for almost all lower UTIs. More complete reporting of cephalexin minimal inhibitory concentrations might have allowed use of this drug for most upper UTIs. Although there was a trend toward shorter duration of therapy for lower versus upper UTI, lower UTIs were always treated for longer than recommended by current guidelines.

80 Family Caregiver Emotional and Communication Needs in Canadian Paediatric Emergency Departments

Abstract Background Paediatric emergency departments (EDs) have been identified as inherently stressful for families, making it challenging to understand and meet families’ global needs, beyond urgent medical care. There is a paucity of research describing how effectively the emotional and communication needs of family caregivers are met during ED visits. Objectives To describe the extent to which family caregivers’ emotional and communication needs were met during paediatric ED visits and relate these findings to visit and demographic characteristics. Design/Methods Electronic surveys with medical record review were deployed at ten Canadian paediatric EDs from October 2018 – March 2020. A convenience sample of families with children &amp;lt;18 years presenting to a paediatric ED were enrolled, for one week every three months, for one year per site. Caregivers completed one survey in the ED and a follow-up survey, up to seven days post-visit. Results This study recruited 2005 caregivers who were mostly 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. Staff physicians (35.6% [535/1502]), bedside nurses (24.2% [364/1502]), residents/medical students (13.8% [207/1502]) and triage nurses (12.4% [186/1502]) were identified as providing the best emotional support to caregivers. 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. Greater triage acuity, being the father (vs. mother), lower caregiver anxiety, respect for the child’s privacy, caregiver involvement in their child’s care, satisfactory updates, and having questions adequately addressed positively impacted caregiver emotional needs. Caregivers feeling less scared during an ED visit, lower caregiver anxiety, caregiver involvement in their child’s care, satisfactory updates, and having questions adequately addressed increased caregiver comfort in caring for their child’s illness at home. Conclusion Approximately 30% of caregivers presenting to paediatric EDs have unmet emotional needs, over 15% have unmet communication needs, and 15% felt inadequately involved in their child’s care, challenging healthcare providers to do better. Family caregiver involvement in care and good communication from ED staff are key elements in improving overall patient experience and satisfaction.

75 Factors that Influence Parental Decision-making Regarding Analgesia for their Children with Musculoskeletal Injury-related Pain: A Qualitative Study

Abstract Background Parents/caregivers are often the gatekeepers for the pharmacologic management of their children’s pain. Parents’ unique expertise in assessing their children’s pain reactions, alongside a deep emotional drive to protect their children, make them invaluable advocates and partners. Parents are highly invested in optimizing pain management outcomes for children. Concerns and preferences regarding medications, including opioids, influence their choices. An improved understanding of caregiver decision-making should encourage a family-centred approach to communication with parents when deciding analgesic plans for children with acute pain, facilitate shared clinical decision-making, and optimize paediatric pain management outcomes in the clinical setting. Objectives Our primary objective was to explore and understand caregiver decision-making as it relates to acute pain management for children presenting to the emergency department, with particular focus on opioids. Design/Methods This qualitative study was embedded within an ongoing paediatric clinical trial (‘The No OUCH Trials’, NCT03767933), which aims to evaluate the clinical efficacy of a combination of oral opioid (hydromorphone) and non-opioid (ibuprofen and acetaminophen) analgesics to manage paediatric musculoskeletal injury-related pain. This study employed one-on-one semi-structured interviews. Parents of children with acute musculoskeletal injuries were recruited from three Canadian paediatric emergency departments (Stollery Children’s Hospital [Edmonton, Alta.], CHU Sainte-Justine [Montreal, Qué.], and Winnipeg Children’s Hospital [Winnipeg, Man.]). Interviews were conducted via telephone from June 2019 to March 2021. Verbatim transcription and thematic analyses occurred concurrently with data collection, supporting data saturation and theory development considerations. Results Twenty-seven interviews were completed. Five major themes regarding pain assessment and treatment emerged: a) My child’s comfort is a priority; b) Every situation is unique; c) Opioids only if necessary; d) Considerations when choosing opioids; and e) Pain research is important. Overall, parents were highly comfortable with their assessment of their child’s pain. Participants’ willingness to use opioid analgesia for their children was primarily dependent on perceptions of injury and pain severity. Although considerations for opioid use were similar between opioid-averse and opioid-willing families, the trade-offs between maximizing pain relief and minimizing risks were weighed differently. Conclusion Our study revealed that parents assess their child’s pain and distress as a global entity, with great confidence in their own assessment and decision-making. For most parents, the desire to relieve their children’s pain outweighed concerns of addiction, misuse, and adverse events when making decisions about opioid analgesia for short-term use. These results can inform evidence-based family-centred approaches to co-decision-making of analgesic plans for children with acute pain.

77 Qualitative Needs Assessment of Child and Caregiver Perspectives to Inform Design of an Artificial Intelligence-enhanced Social Robot to Improve Paediatric Emergency Care

Abstract Background Children routinely experience under-treated pain and distress related to medical procedures, such as intravenous insertions (IVI), which can have negative consequences in both the short-term (e.g., fear, inability to complete procedure) and long-term (e.g., needle phobia, healthcare avoidance). Socially assistive robots (SARs) are a promising tool to manage pain and distress in paediatric healthcare settings. As we work towards building a more developmentally adaptive and interactive SAR, we must first understand how children and families perceive SAR to create a safe and ethical tool. Objectives The aim of this study was to understand children’s and caregivers’ perceptions of interacting with an artificial intelligence (AI)-enhanced SAR as a distraction tool in the paediatric emergency department (ED) to improve their IVI experience. Design/Methods We conducted semi-structured interviews and focus groups with children and their caregivers from two Canadian paediatric EDs between April 2021 to January 2022, with interview transcription and analysis conducted concurrently until thematic saturation was achieved. Qualitative content analysis was performed independently by two team members, who met regularly to discuss the coding scheme and key themes, and facilitate iterative adjustments to the interview script based on emerging themes. Results Nineteen children (mean age 8.42 years [SD 2.21]) and twelve caregivers were included. Three main themes were identified: (1) Overall ED experience, (2) General acceptance of a SAR, and (3) Suggested SAR features to support child engagement. Most participants were comfortable in the ED but identified long wait times and lack of technological supports (e.g., iPads) as an impediment to positive experience. Most participants expressed excitement and comfort surrounding robot technology. However, concerns were raised about photo/video capture by the SAR and the possibility of technical failure resulting in child disappointment or disengagement. Suggestions for potential robot features were unique to the phase of IVI: before IVI (developmentally appropriate procedure explanation, creation of a shared distraction plan); during IVI (variety and choice of distractions, SAR capability to stop or alter course); and after IVI (debriefing and positive reinforcement). Conclusion Overall, AI-enhanced SARs were perceived by children and caregivers as a promising tool to distract children. Insights collected will be used to inform the ethical and emotionally safe design of an AI-enhanced SAR. Next steps include development and usability testing of the SAR, subsequent evaluation in the paediatric ED via a randomized controlled trial, and clinical implementation.

Perspectives of Healthcare Providers to Inform the Design of an AI-Enhanced Social Robot in the Pediatric Emergency Department.

Children commonly experience pain and distress in healthcare settings related to medical procedures such as blood tests and intravenous insertions (IVIs). Inadequately addressed pain and distress can result in both short- and long-term negative consequences. The use of socially assistive robotics (SARs) to reduce procedure-related distress and pain in children's healthcare settings has shown promise; however, the current options lack autonomous adaptability. This study presents a descriptive qualitative needs assessment of healthcare providers (HCPs) in two Canadian pediatric emergency departments (ED) to inform the design an artificial intelligence (AI)-enhanced social robot to be used as a distraction tool in the ED to facilitate IVIs. Semi-structured virtual individual and focus group interviews were conducted with eleven HCPs. Four main themes were identified: (1) common challenges during IVIs (i.e., child distress and resource limitations), (2) available tools for pain and distress management during IVIs (i.e., pharmacological and non-pharmacological), (3) response to SAR appearance and functionality (i.e., personalized emotional support, adaptive distraction based on child's preferences, and positive reinforcement), and (4) anticipated benefits and challenges of SAR in the ED (i.e., ensuring developmentally appropriate interactions and space limitations). HCPs perceive AI-enhanced social robots as a promising tool for distraction during IVIs in the ED.

Machine learning to identify attributes that predict patients who leave without being seen in a pediatric emergency department.

To characterize patients who left without being seen (LWBS) from a Canadian pediatric Emergency Department (ED) and create predictive models using machine learning to identify key attributes associated with LWBS. We analyzed administrative ED data from April 1, 2017, to March 31, 2020, from IWK Health ED in Halifax, NS. Variables included: visit disposition; Canadian Triage Acuity Scale (CTAS); triage month, week, day, hour, minute, and day of the week; sex; age; postal code; access to primary care provider; visit payor; referral source; arrival by ambulance; main problem (ICD10); length of stay in minutes; driving distance in minutes; and ED patient load. The data were randomly divided into training (80%) and test datasets (20%). Five supervised machine learning binary classification algorithms were implemented to train models to predict LWBS patients. We balanced the dataset using Synthetic Minority Oversampling Technique (SMOTE) and used grid search for hyperparameter tuning of our models. Model evaluation was made using sensitivity and recall on the test dataset. The dataset included 101,266 ED visits where 2009 (2%) records were excluded and 5800 LWBS (5.7%). The highest-performing machine learning model with 16 patient attributes was XGBoost which was able to identify LWBS patients with 95% recall and 87% sensitivity. The most influential attributes in this model were ED patient load, triage hour, driving minutes from home address to ED, length of stay (minutes since triage), and age. Our analysis showed that machine learning models can be used on administrative data to predict patients who LWBS in a Canadian pediatric ED. From 16 variables, we identified the five most influential model attributes. System-level interventions to improve patient flow have shown promise for reducing LWBS in some centres. Predicting patients likely to LWBS raises the possibility of individual patient-level interventions to mitigate LWBS.

Prevalence and characterization of food insecurity in a Canadian paediatric emergency department.

Food insecurity (FI) is associated with a number of adverse child health outcomes and increased emergency department (ED) use. The COVID-19 pandemic exacerbated the financial hardship faced by many families. We sought to determine the prevalence of FI among children with ED visits, compare this to pre-pandemic rates, and describe associated risk factors. From September to December 2021, families presenting to a Canadian paediatric ED were asked to complete a survey screening for FI along with health and demographic information. Results were compared to data collected in 2012. Multivariable logistic regression was used to measure associations with FI. In 2021, 26% (n = 173/665) of families identified as food insecure compared to 22.7% in 2012 (n = 146/644) a difference of 3.3% (95% CI [-1.4%, 8.1%]). In multivariable analysis, greater number of children in the home (OR 1.19, 95% CI [1.01, 1.41]), financial strain from medical expenses (OR 5.31, 95% CI [3.45, 8.18]), and a lack of primary care access (OR 1.27, 95% CI [1.08, 1.51]) were independent predictors of FI. Less than half of families with FI reported use of food charity, most commonly food banks, while one-quarter received help from family or friends. Families experiencing FI expressed a preference for support through free or low-cost meals and financial assistance with medical expenses. More than one in four families attending a paediatric ED screened positive for FI. Future research is needed to examine the effect of support interventions for families assessed in medical care facilities including financial support for those with chronic medical conditions.