Emergency Care For Children Research Articles

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies.

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

The Quality of Pre-Hospital Emergency Care for Children with Acute Abdominal Pain: The Prospective Cohort Study Results

Background. Introduction of laboratory rapid tests into the practice of emergency teams (EMS) and carrying out a simple etiologic point-of-care diagnosis can affect the quality of medical care for children at subsequent stages. Objective. Our aim was to assess the quality of pre-hospital emergency care for children with acute abdominal pain using laboratory rapid tests. Methods. An open prospective comparative randomized study was conducted. Patients who called an emergency team for acute abdominal pain were randomized into two groups. In the study group (n = 243), the proposed model of pre-hospital emergency care with laboratory rapid tests was used. With patients of the control group (n = 242), the emergency teams worked according to the traditional schedule. The quality of medical care for children was assessed taking into account the emergency team specialty. We also carried out the analysis of case management in case of admission to a surgical department. Results. In the study group, the frequency of refusals of hospitalization was 2.5 times lower; the frequency of repeated calls was 75% less; unreasonable admission to a surgical department was 1.5 times less than in the control group (p < 0.05 for all parameters). Non-specialized hospitalization was 5% in the control group no cases in the study group. Conclusion. The use of a laboratory rapid point-of-care diagnosis at the pre-hospital stage helps to improve the quality of care for children with acute abdominal pain.

Emergency Care for Children in the United States: Epidemiology and Trends Over Time

BackgroundThe emergency care system for children in the United States is fragmented. A description of epidemiological trends based on emergency department (ED) volume over time could help focus efforts to improve emergency care for children. ObjectivesTo describe the trends of emergency care for children in the United States from 2006–2014 in EDs across different pediatric volumes. MethodsWe analyzed pediatric visits to EDs using the Health Care Utilization Project Nationwide Emergency Department Sample in a representative sample of 1,000 EDs annually from 2006–2014. We report trends in disease severity, mortality, and transfers based on strata by pediatric volume and other hospital characteristics. ResultsFrom 2006–2014, there were 318,114,990 pediatric ED visits. Pediatric visits remained steady but declined as a percentage of total visits (−3.91%, p = 0.0007). The majority (92.7%) of children were cared for in lower-volume EDs (<50,000 pediatric visits/year), where mortality was higher vs. the highest-volume EDs. Mortality decreased over time (0.34/1,000 to 0.27, p = 0.0099), whereas interhospital transfers increased (p = 0.0020). ED visits increased for children with Medicaid insurance (40.7% to 56.7%, p < 0.0001), whereas rates of self-pay insurance decreased (13.6% to 9.45%, p = 0.0006). The most common reasons for pediatric ED visits were trauma (25.6%); ear, nose, and throat; dental/mouth disorders (21.8%); gastrointestinal diseases (17.0%); and respiratory diseases (15.6%). ConclusionsOverall, pediatric ED visits have remained stable, with lower mortality rates, whereas Medicaid-funded pediatric visits have increased over time. Most children still seek care in lower-volume EDs. Efforts to improve pediatric care could be best focused on lower-volume EDs and interhospital transfers.

P024: Sharing evidence, experiences and expertise: the value of networking to standardize emergency care for kids in Canada

Introduction: TREKK is a national knowledge mobilization network of clinicians, researchers and parents aimed at improving emergency care for children by increasing collaborations between general and pediatric emergency departments (ED). This study aimed to determine patterns of knowledge sharing within the network and identify connections, barriers and opportunities to obtaining pediatric information and training. Methods: Social network analysis (SNA) uses network theory to understand patterns of interaction. Two SNAs were conducted in 2014 and 2015 using an online network survey distributed to 37 general EDs. Data was analyzed using UCI Net and Netdraw to identify connections, knowledge sharing and knowledge brokers within the network. Building on these results, we then conducted 22 semi-structured follow-up interviews (2016) with healthcare professionals (HCPs) at General EDs across Canada, purposefully sampled to include individuals from connected and disconnected sites, as identified in the SNA. Interviews were analyzed by 2 reviewers using content and thematic analysis. Results: SNA data was analyzed for 135 participants across the network. Results from 2014 showed that the network was divided along provincial lines, with most individuals connecting with colleagues within their own institution. Results from 2015 showed more inter-site interconnectivity and a reduction in isolated sites over time from 17 to 3. Interview participants included physicians (59%) and nurses (41%) from 18 general EDs in urban (68%) and rural/remote (32%) Canada. HCPs sought information both formally and informally, by using guidelines, talking to colleagues, and attending pediatric related training sessions. Network structure and processes were felt to increase connections, support practice change, and promote standards of care. Participants identified personal, organizational and system-level barriers to information and skill acquisition, including resources and personal costs, geography, dissemination, and time. Providing easy access to information at the point of care was promoted through enhancing content visibility and by embedding resources into local systems. There remains a need to share successful methods of local dissemination and implementation across the network, and to leverage local professional champions such as clinical nurse liaisons. Conclusion: This study highlights the power of a network to increase connections between HCPs working in general and pediatric EDs. Findings reinforce the critical role of ongoing network evaluation to improve the design and delivery of knowledge mobilization initiatives.

Not all emergency departments are alike

A medical emergency requires timely, immediate care. With that in mind, the notion that certain conditions require special expertise is not new, nor the concept that outcomes are improved when emergent care is provided in specified centers rather than in the closest available emergency department (ED). The result is the creation of trauma centers, stroke centers, and the like. The same could be said for the ability to render appropriate care to children. A prior project, the National Pediatric Readiness Project, surveyed EDs nationwide for availability of pediatric-specific equipment, personnel, and processes, and created a weighted score for pediatric readiness. A score of 100 indicates that essential requirements are met for pediatric readiness. A prior study showed that the median score nationally is 68.9 (JAMA Pediatr 2015;169:527-34). In this volume of The Journal, Ray et al address the issue of geographic accessibility to emergency care for children. The authors examined the percentage of children living within 30 minutes of a pediatric-ready ED as defined by the National Pediatric Readiness Project. The results are striking—while 93.7% live within 30 minutes of any ED, only one-third live within 30 minutes of an ED scoring 100, and a little over one-half live within 30 minutes of those scoring in the 90th percentile of readiness; 70% live within an ED scoring within the 75th percentile. The policy implications are clear—the gaps were not in availability of an ED, but in lack of EDs with high pediatric readiness. This means that children presenting to those EDs may not have access to age-appropriate equipment, personnel, or processes, a concern for both families and providers. Fortunately there are already programs aimed at improving pediatric readiness, such as the quality improvement efforts of the Emergency Medical Services for Children (EMSC) program (https://emscimprovement.center/). When considering the well-being of our children, this sort of geographical analysis may permit focused, effective investment, and improved outcomes. Article page 225 ▶ Access to High Pediatric-Readiness Emergency Care in the United StatesThe Journal of PediatricsVol. 194PreviewTo determine the geographic accessibility of emergency departments (EDs) with high pediatric readiness by assessing the percentage of US children living within a 30-minute drive time of an ED with high pediatric readiness, as defined by collaboratively developed published guidelines. Full-Text PDF

Knowledge sharing between general and pediatric emergency departments: connections, barriers, and opportunities.

Translating Emergency Knowledge for Kids (TREKK) is a national network aimed at improving emergency care for children by increasing collaborations and knowledge sharing between general and pediatric emergency departments (EDs). This study aimed to determine patterns of knowledge sharing within the network and to identify connections, barriers, and opportunities to obtaining pediatric information and training. We conducted 22 semi-structured interviews with health care professionals working in general EDs, purposefully sampled to represent connected and disconnected sites, based on two previous internal quantitative social network analyses (SNA). Data were analyzed by two independent reviewers. Participants included physicians (59%) and nurses (41%) from 18 general EDs in urban (68%) and rural/remote (32%) Canada. Health care professionals sought information both formally and informally, by using guidelines, talking to colleagues, and attending pediatric related training sessions. Network structure and processes were found to increase connections, support practice change, and promote standards of care. Participants identified personal, organizational and system level barriers to information and skill acquisition, including resources and personal costs, geography, dissemination, and time. Providing easy access to information at the point of care was promoted through enhancing content visibility and by embedding resources into local systems. There remains a need to share successful methods of local dissemination and implementation across the network, and to leverage local professional champions such as clinical nurse liaisons. These findings reinforce the critical role of ongoing network evaluation to improve the design and delivery of knowledge mobilization initiatives.

Combining Natural Ingredients and Beliefs: The Dayak Tribe’s Experience Caring for Sick Children with Traditional Medicine

ABSTRACTInstead of seeking conventional health care, the Dayak tribe in Borneo, Indonesia, treats sick children at home with traditional medicine. The objective of this descriptive, qualitative study was to explore the Dayak tribe’s use of traditional medicine to care for sick children. Comprehensive interviews were conducted with 10 caregivers, with collected data analyzed using content analysis. Key recurring themes identified were: 1) traditional medicine as first aid; 2) ease of access and cost-effectiveness; 3) traditional medicine was not always effective; 4) a combination of natural ingredients and beliefs; 5) the importance of “communicating” with plants; and 6) engagement with metaphysical forces. Health professionals should respect familial cultures’ beliefs regarding the provision of health care at home. Furthermore, they need to develop competency in performing cultural assessments and providing information to these parents on the risks of not seeking professional emergency care for children with conditions that can’t be handled at home with traditional medicine.

Emergency Department Utilization by Children in the USA, 2010-2011.

IntroductionEpidemiological surveillance data for emergency department (ED) visits by children are imperative to guide resource allocation and to develop health policies that advance pediatric emergency care. However, there are sparse population-based data on patient-level information (e.g., the number of children who present to the emergency department [ED]). In this context, we aimed to investigate both the patient- and visit-level rates of ED utilization by children.MethodsThis was a retrospective cohort study using population-based multipayer data – state ED databases (SEDD) and state inpatient databases (SID) – from six geographically-dispersed U.S. states (California, Florida, Iowa, Nebraska, New York, and Utah) in 2010 and 2011. We identified all children aged <18 years who presented to the ED and described the patient-level ED visit rate, visit-level ED visit rate, and proportion of all ED visits made by children. We conducted the analysis using the 2011 SEDD and SID data. We also repeated the analysis using the 2010 data to determine the consistency of the results across different years.ResultsIn 2011, 2.9 million children with a patient identifier presented to EDs in the six U.S. states. At the patient-level, 15 out of every 100 children presented to an ED at least once per year. Of these children, 25% presented to EDs 2–3 times per year with an approximately 1.5-fold variation across the states (e.g., 19% in Utah vs. 28% in Florida). In addition, 5% presented to EDs ≥4 times per year. At the visit-level, 6.7 million ED visits were made by children in 2011 – 34 ED visits per 100 children annually. ED visits by children accounted for 22% of all ED visits (including both adults and children), with a relatively small variation across the states (e.g., 20% in New York vs. 24% in Nebraska). Analysis of the 2010 data gave similar results for the ED utilization by children.ConclusionBy using large population-based data, we found a substantial burden of ED visits at both patient- and visit-levels. These findings provide a strong foundation for policy makers and professional organizations to strengthen emergency care for children.

Assessing process of paediatric care in a resource-limited setting: a cross-sectional audit of district hospitals in Rwanda

Background: Routine assessment of quality of care helps identify deficiencies which need to be improved. While gaps in the emergency care of children have been documented across sub-Saharan Africa, data from Rwanda are lacking.Objective: To assess the care of sick infants and children admitted to Rwandan district hospitals and the extent to which it follows currently recommended clinical practice guidelines in Rwanda.Methods: Data were gathered during a retrospective cross-sectional audit of eight district hospitals across Rwanda in 2012/2013. Medical records were randomly selected from each hospital and were reviewed to assess the process of care, focusing on the leading causes of under-5 mortality, including neonatal conditions, pneumonia, malaria and dehydration/diarrhoea.Results: Altogether, 522 medical records were reviewed. Overall completion of a structured neonatal admission record was above 85% (range 78.6–90.0%) and its use was associated with better documentation of key neonatal signs (median score 6/8 and 2/8 when used and not used, respectively). Deficiencies in the processes of care were identified across hospitals and there were rural/urban disparities for some indicators. For example, neonates admitted to urban district hospitals were more likely to receive treatment consistent with currently recommended guidelines [e.g. gentamicin (OR 2.52, 95% CI 1.03–6.43) and fluids (OR 2.69, 95% CI 1.2–6.2)] than those in rural hospitals. Likewise, children with pneumonia admitted to urban hospitals were more likely to receive the correct dosage of gentamicin (OR 4.47, 95% CI 1.21–25.1) and to have their treatment monitored (OR 3.75, 95% CI 1.57–8.3) than in rural hospitals. Furthermore, children diagnosed with malaria and admitted to urban hospitals were more likely to have their treatment (OR 2.7, 95% CI 1.15–6.41) monitored than those in rural hospitals.Conclusions: Substantial gaps were identified in the process of neonatal and paediatric care across district hospitals in Rwanda. There is a need to (i) train health care professionals in providing neonatal and paediatric care according to nationally adopted clinical practice guidelines (e.g. ETAT+); (ii) establish a supervision and mentoring programme to ensure that the guidelines are available and used appropriately in district hospitals; and (iii) use admission checklists (e.g. neonatal and paediatric admission records) in district hospitals.

Emergency medical services responders’ perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study

ObjectivePrehospital emergency medical services (EMS) providers report anxiety as the second most common contributor to paediatric patient safety events. The objective of this study was to understand how EMS providers...

The Influence of Quality Assurance and Supportive Supervision on the Quality of Medical Care in Children’s Hospitals of the Municipal Level of the Rostov Region

Background . Improving the quality of medical care is the absolute priority of the World Health Organization and all socially-oriented ministries and departments around the world. Objective . Our aim was to evaluate the effectiveness of quality assurance and supportive supervision in municipal hospitals to improve the quality of medical care for children (by the example of the Rostov region). Methods. The open observational study included 10 second-level hospitals in the Rostov Region. At the start of the project, the quality of inpatient care for children in the region was audited based on recommendations and tools of the World Health Organization, and training of medical personnel was organized. Monitoring visits to hospitals were carried out by experts every 3 months (supportive supervision). Reaudit of the quality of care was conducted a year later. Results. As a result of regular quality assurance and supportive supervision of hospitals during the first year of operation, such indicators of the quality of medical care as the availability of medical equipment for emergency care for children, the infrastructure of children’s departments, the triage and provision of emergency care in children’s departments, managing patients with various acute conditions (fever, diarrhea, respiratory diseases), supporting care, internal quality assurance, accessibility to standards of care and clinical guidelines for the diagnosis and treatment of various diseases, respect for children’s rights were significantly (p < 0.05) improved. Conclusion. Supportive supervision and regular external quality assurances of hospitals contribute to a rapid increase in the quality of medical care for children.

Parental and Pediatricians' Perception of Need for Subspecialty Training in Pediatric Emergency Medicine for Delivering Emergency Care to Pediatric Patients.

The quality of pediatric emergency care may depend on the competence of the emergency department physicians. It is important to know whether parents and general pediatricians associate the quality of pediatric emergency care with the pediatric emergency medicine (PEM) training of the emergency department physicians. We designed the study to determine parental and pediatricians’ opinion and expectation in regard to this question. Most of the surveyed parents’ and pediatricians’ recognize the importance of PEM training and believed that physicians trained in PEM can provide better emergency care for children. However, 53.8% of parents, especially Spanish speaking and with Medicaid/no insurance coverage, believe that the emergency care provided for their children by general pediatricians and PEM physicians is equivalent. The results of our study could be utilized by accredited PEM planners in the creation of strategies to ensure the quality of emergency care for children population.

A Novel Curriculum to Optimize Emergency Medicine Residents' Exposure to Pediatrics.

Recognizing the profound impact that emergency medicine residency graduates have on the quality of the emergency care of children, residency training programs must provide a broad clinical experience and training in pediatric care. Traditionally, part of this training has included a hospital ward rotation in inpatient pediatrics. However, these experiences may be perceived by learners as being educationally low-yield in terms of direct applicability to the practice of emergency medicine. This educational innovation describes the development of a novel curriculum for teaching pediatrics to emergency medicine residents. Rather than focusing on tasks disconnected from emergency medicine practice, residents provide the initial clinical care for patients in the emergency department in a professional setting situated to mirror their ultimate professional practice. The innovation involves longitudinal patient follow-up, with mentored supervision and discussion to reinforce learning. The curriculum includes dedicated Pediatric ED time, deliberate inpatient and phone follow-up, ward rounds, focused pediatric topics, and direct observation assessment and feedback on pediatric clinical skills. This novel curriculum emphasizes the importance of situated learning, and is one component of a longitudinal teaching plan for pediatrics within an emergency medicine residency.

Emergency Dental Care of Children and Adolescents in Basic Health Unit and Emergency Care Unit

Objective: To evaluate the factors related to the dental emergency care of children and adolescents in Basic Health Units (UBS) and Emergency Care Units (UPA) affiliated with the public dental network of Curitiba, Brazil. Material and Methods: Cross-sectional study that evaluated 1,012 emergency cases in individuals aged up to 17 years old and with a permanent record in the Unified Health System of Curitiba. Demographic data of individuals and of services were taken from electronic medical records. Statistical analysis was performed using the chi-square test and chi-square test for linear trend (α = 0.05), estimating the prevalence ratio (PR) (95%CI). Results: Of the total of emergency cases, 68.2% and 31.8% were of children and adolescents, respectively. UBS accounted for 89.7% of the cases while UPA represented 10.3%, and 12.2% of the treatments were characterized as first access to the system. Adolescents used UPAs for emergency care more often than children (PR = 1.84; 95%CI: 1.28-2.64). Among children, those with more than 1 year since the last appointment used UPAs for emergency care more often (PR = 1.86; 95%CI: 1.09-3.17). Adolescents for whom emergency care was characterized as first access to the system used UPAs more often (PR = 2.16; 95%CI: 1.04-4.46). The proximity between the UBS of origin and the UPA was associated with greater UPA utilization by both groups. Conclusion: UBSs accounted for most of the dental emergency treatments. Children and adolescents with a poorer connection with UBSs and those who lived near an UPA had a higher prevalence of UPA utilization for emergency care.

14 The Impact of a Pediatric Emergency Department Designation System on Pediatric Injury Mortality Rates in Arizona

Currently, access to optimal emergency care for children is affected by multiple barriers, including, lack of availability of equipment, appropriately trained staff, and timely transfer to definitive care. Fourteen states, including Arizona have developed a regional or statewide system for pediatric emergency care. These programs aim to provide well-defined standards mandating critical resources required to provide effective care for children. While pediatric verification programs are associated with greater pediatric preparedness, outcome data has been lacking to track the effects and patient-centered outcomes of implementing such systems. Our aim is to describe the pediatric injury mortality outcomes of implementing a pediatric designation system within Arizona. This was a cross-sectional study conducted using data from emergency department visits and inpatient hospitalizations between 2011 and 2014 using the Arizona Hospital Discharge Database. Facilities certified between 2011 and 2014 were included in the analysis. Primary outcome measures were the pediatric emergency department injury mortality rate pre and post-certification. All records prior to certification were included in the pre-certification group. Once facilities were certified, all subsequent records during the month of certification were moved into the post-certification group. The pediatric emergency department mortality rates were calculated by dividing the total of pediatric ED visits by the number of deaths for each group, multiplied by 100,000 to equal the pediatric emergency department mortality rate per 100,000 visits. Pediatric injury mortality in Arizona emergency departments varied from 39.8 deaths per 100,000 ED visits to 25.6 deaths per 100,000 ED visits in the pre-certification and post-certification groups, respectively. Comparing the certified emergency department’s pediatric mortality rate to the overall pediatric injury mortality rate demonstrated 25.6 deaths versus 35.5 deaths respectively. Analysis of the pediatric mortality rates per 1,000 hospitalizations in the time period before initiation of the designation program (2009-2011) to the time period following initiation of the program (2012-2014) demonstrated a greater rate difference between certified and non-certified hospitals post-certification (7.9 versus 10.2 and 10.8 versus 17.5; respectively). The Arizona emergency department pediatric designation system resulted in a decrease in pediatric injury mortality post certification. Institutional certification also resulted in a reduction of inpatient pediatric injury mortality when compared to the non-certified hospitals in the same time period.

Prioritising minimum standards of emergency care for children in resource-limited settings

Background: There is global variation in the ability of hospital-based emergency centres to provide paediatric emergency medicine (PEM) services. Although minimum standards have been proposed, they may not be applicable in resource-limited settings.Objective:The goal was to identify reasonable minimum standards to provide safe and effective care for acutely ill children in resource-limited settings.Methods: Using previously proposed standards from the International Federation of Emergency Medicine (IFEM), a modified Delphi approach was used to reach agreement regarding minimum standards for PEM in resource-limited settings. Three rounds of surveys were electronically distributed to physicians working in resource-limited settings. Those standards with >67% agreement advanced to the subsequent round.Results: The categories of the surviving criteria included integrated service design, child and family-friendly care, initial assessment of the ill child, stabilising and treating an ill child, staff training and competence, equipment, supplies and medications, quality and safety, child protection, and advanced training and academic research.Conclusions: Experts with experience in acute care of children in resource-limited settings have prioritised standards for paediatric emergency care. They identified 26 variables in nine domains from the original IFEM list of standards and two additional free text standards for the care of acutely ill children. This list may serve as a helpful guide for emergency centres to provide medical treatment for acutely ill children in resource-limited settings.

Safety of the Manchester Triage System to Detect Critically Ill Children at the Emergency Department

To assess the safety of the Manchester Triage System in pediatric emergency care for children who require admission to the intensive care unit (ICU). Between 2006 and 2013, 50 062 consecutive emergency department visits of children younger than the age of 16 years were included. We determined the percentage of undertriage, defined as the proportion of children admitted to ICU triaged as low urgent according to the Manchester Triage System, and diagnostic performance measures, including sensitivity, specificity, and diagnostic OR. Characteristics of undertriaged patients were compared with correctly triaged patients. In a logistic regression model, risk factors for undertriage were determined. In total, 238 (28.7%) of the 830 children admitted to ICU during the study period were undertriaged. Sensitivity of high Manchester Triage System urgency levels to detect ICU admission was 71% (95% CI 68%-74%) and specificity 85% (95% CI 85%-85%). Severity of illness was lower in undertriaged children than correctly triaged children admitted to ICU. Risk factors for undertriage were age <3 months, medical presenting problem, comorbidity, referral by a medical specialist or emergency medical services, and presentation during the evening or night shift. The Manchester Triage System misclassifies a substantial number of children who require ICU admission. Modifications targeted at young children and children with a comorbid condition could possibly improve safety of the Manchester Triage System in pediatric emergency care.

How a short stay unit can reduce children's waiting times.

Admitting children to emergency departments (EDs) often places them in an environment better suited to the treatment of adult patients. These children are often triaged and treated as adults, resulting in children being given the wrong triage categories and having their treatment delayed. EDs have problems giving drugs to children, staff are unfamiliar with children's emergency care, and children find EDs frightening. A paediatric emergency short stay unit (PESSU) was opened at Caboolture Hospital, Queensland, Australia, in January 2014. Admission to the PESSU has significantly reduced waiting times for children arriving at the ED and enabled specialist nursing and medical care to be provided quickly. This has been supported by the development of the paediatric flow nurse role ( Gray et al 2016 ).

"What you will": Results of an Empirical Analysis of the Need to Improve Work-life Balance for Physicians

This study assessed the perceived need for clinics to improve work-life balance of physicians. Hospitals are increasingly facing demands to offer physicians working conditions that allow greater balance between family life and pursuit of career. Simultaneously, hospitals could consider this an opportunity to stand out as attractive employers. N=120 doctors of the medical faculty and N=679 medical students in their premedical and clinical training participated online. The results of the Work-Family/Family-Work Conflict Scale (WFC/FWC) showed physicians to have a decreased work/life balance when starting to work professionally, especially with a child. Ninety percent of the respondents considered the following arrangements to be especially helpful: temporary work interruptions in an emergency, part-time positions or emergency childcare. The doctors also expressed their wish to be actively supported by their supervisors on the topic of work/life balance. This analysis on work-family balance shows the need for change in the studied samples. Based on the measures that were determined to be helpful, hospitals can make conclusions about what concrete steps of action can be taken. Additionally, WFC/FWC could be used as a standardized analysis measure to assess the load imposed on physicians by family on work place and vice versa.

Toward Practice Advancement in Emergency Care for Children With Autism Spectrum Disorder.

There is increasing recognition that children with autism spectrum disorder (ASD) experience challenges in busy clinical environments such as the emergency department (ED). ASD may heighten adverse responses to sensory input or transitions, which can impose greater difficulty for a child to cope with situational demands. These problems can be amplified in the ED because of its busy and unpredictable nature, wait times, and bodily care. There is little literature documenting ED-based needs of children with ASD to inform clinical guidelines. The objective was to identify stakeholder perspectives in determining clinical priorities and recommendations to guide ED service delivery for children with ASD. After qualitative interviews with children, parents, and health care providers conducted in a previous phase of this study, focus groups were convened with parents of children with ASD, ED clinicians, and ED administrators (total n = 60). Qualitative data were analyzed based on an interpretive description approach. Participants identified the ED and its delivery of care as insufficient to meet the unique needs of children with ASD. The following clinical priorities were identified: ASD-focused preparedness for ED procedures and processes, wait time management, proactive strategies for sedation and restraint, child-focused support, health care provider capacity building, post-ED follow-up resources, and transition planning to adult care. Heightened child- and family-centered care were strongly recommended.