Pediatric Health Care Delivery Research Articles

Horizontally integrated health systems and neonatal intensive care unit (NICU) care for very preterm infants.

Hospital care has consolidated rapidly into health systems in the United States. Infants born very preterm are among the most vulnerable pediatric populations, accounting for the majority of infant deaths each year. The pediatric health care delivery system for infants is unique as the birth hospitalization includes 2 patients, the mother and the infant. Further, regionalization goals for infants who are born preterm require care to be provided at neonatal intensive care units (NICUs) with the capacity to treat them. National patient-level data from the Vermont Oxford Network demonstrates that most very preterm infants were born in a horizontally integrated, multi-hospital system (84%), and they tended to remain in the system for their entire hospitalization, including for risk-appropriate NICU care. Half of the infants were cared for in large systems with more than 10 hospitals that were disproportionately cross-market systems. With high transfer rates between hospitals (21%) it will be important to determine the implications of consolidation for the quality of care and patient-centeredness for families. The care for very preterm infants is important from a policy perspective as hospitalized newborn infants account for 21% of hospitalizations in Medicaid each year and 10% of aggregate hospital costs.

Evaluation Strategies for Understanding Experiences With Virtual Care in Canada: Mixed Methods Study.

Virtual care was rapidly integrated into pediatric health services during the COVID-19 pandemic. While virtual care offers many benefits, it is necessary to better understand the experiences of those who receive, deliver, and coordinate virtual care in order to support sustainable, high-quality, and patient-centered health care. To date, methods implemented to evaluate users' experiences of virtual care have been highly variable, making comparison and data synthesis difficult. This study aims to describe evaluation strategies currently used to understand personal experiences with pediatric virtual care in Canada. In this mixed methods environmental scan, we first distributed a web-based questionnaire to clinical, research, and operational leaders delivering and evaluating pediatric virtual care in Canada. The questionnaire collected information about how experiences with virtual care have been or are currently being evaluated and whether these evaluations included the perspectives of children or youth, families, providers, or support staff. Second, respondents were asked to share the questions they used in their evaluations, and a content analysis was performed to identify common question categories. Third, we conducted semistructured interviews to further explore our respondents' evaluation experiences across 4 domains-evaluation approaches, distribution methods, response rates, and lessons learned-and interest in a core set of questions for future evaluations. There were 72 respondents to the web-based questionnaire; among those who had conducted an evaluation, we identified 15 unique evaluations, and 14 of those provided a copy of the tools used to evaluate virtual care. These evaluations measured the virtual care experiences of parents or caregivers (n=15, 100%), children or youth (n=11, 73%), health care providers (n=11, 73%), and support staff (n=4, 27%). The most common data collection method used was electronic questionnaires distributed by email. Two respondents used validated tools; the remainder modified existing tools or developed new tools. Content analysis of the 14 submitted questionnaires revealed that the most common questions were about overall participant satisfaction, the comparison of virtual care to in-person care, and whether participants would choose virtual care options in the future. Interview findings indicate respondents frequently relied on methods used by peers and that a standardized, core set of questions to evaluate experiences with virtual care would be helpful to improve evaluation practices and support pediatric health care delivery. At our institution and elsewhere in Canada, experiences with pediatric virtual care have been evaluated using a variety of methods. A more consistent evaluation approach using standardized tools may enable more regular comparisons of experiences with virtual care and the synthesis of findings across health care settings. In turn, this may better inform our approach to virtual care, improve its integration into health systems, and facilitate sustainable, high-quality, patient-centered care.

A pediatric virtual care evaluation framework and its evolution using consensus methods

BackgroundThe use of virtual care has increased dramatically in response to the COVID-19 pandemic, yet evidence is lacking regarding the impact of virtual care on patient outcomes, particularly in pediatrics. A standardized evaluation approach is required to support the integration of virtual care into pediatric health care delivery programs. The objective of this work was to develop a comprehensive and structured framework for pediatric virtual care evaluation. This framework is intended to engage and guide care providers, health centres, and stakeholders towards the development of a standardized approach to the evaluation of pediatric virtual care.MethodsWe brought together a diverse multidisciplinary team, including pediatric clinicians, researchers, digital health leads and analysts, program leaders, a human factors engineer, a family advisor and our manager of health equity and diversity. The team reviewed the literature, including published evaluation frameworks, and used a consensus-based method to develop a virtual care evaluation framework applicable to a broad spectrum of pediatric virtual care programs. We used an iterative process to develop framework components, including domains and sub-domains, examples of evaluation questions, measures, and data sources. Team members met repeatedly over seven months to generate and provide feedback on all components of the framework, making revision as needed until consensus was reached. The framework was then applied to an existing virtual care program.ResultsThe resulting framework includes four domains (health outcomes, health delivery, individual experience, and program implementation) and 19 sub-domains designed to support the development and evaluation of pediatric virtual care programs. We also developed guidance on how to use the framework and illustrate its utility by applying it to an existing pediatric virtual care program.ConclusionsThis virtual care evaluation framework expands on previously developed frameworks by providing additional detail and a structure that supports practical application. It can be used to evaluate a wide range of pediatric virtual care programs in a standardized manner. Use of this comprehensive yet easy to use evaluation framework will inform appropriate implementation and integration of virtual care into routine practice and support its sustainability and continuous improvement.

Utilizing big data from electronic health records in pediatric clinical care.

Big data has the capacity to transform both pediatric healthcare delivery and research, but its potential has yet to be fully realized. Curation of large multi-institutional datasets of high-quality data has allowed for significant advances in the timeliness of quality improvement efforts. Improved access to large datasets and computational power have also paved the way for the development of high-performing, data-driven decision support tools and precision medicine approaches. However, implementation of these approaches and tools into pediatric practice has been hindered by challenges in our ability to adequately capture the heterogeneity of the pediatric population as well as the nuanced complexities of pediatric diseases such as sepsis. Moreover, there are large gaps in knowledge and definitive evidence demonstrating the utility, usability, and effectiveness of these types of tools in pediatric practice, which presents significant challenges to provider willingness to leverage these solutions. The next wave of transformation for pediatric healthcare delivery and research through big data and sophisticated analytics will require focusing efforts on strategies to overcome cultural barriers to adoption and acceptance. IMPACT: Big data from EHRs can be used to drive improvement in pediatric clinical care. Clinical decision support, artificial intelligence, machine learning, and precision medicine can transform pediatric care using big data from the EHR. This article provides a review of barriers and enablers for the effective use of data analytics in pediatric clinical care using pediatric sepsis as a use case. The impact of this review is that it will inform influencers of pediatric care about the importance of current trends in data analytics and its use in improving outcomes of care through EHR-based strategies.

National survey of health services provided by pediatric post-acute care facilities in the US.

The need for pediatric post-acute facility care (PAC) is growing due to technological advances that extend the lives of many children, especially those with complex medical needs. The objectives were to describe [1] the types and settings of PAC; [2] the clinical characteristics of the pediatric patients requiring PAC; and [3] perceptions of PAC care delivery by clinical staff. An online survey was administered between 6/2018 to 12/2018 to administrative leaders in PAC facilities that have licensed beds for children and who were active members of the Pediatric Complex Care Association. Survey topics included types of health services provided; pediatric patient characteristics; clinical personnel characteristics; and perceptions of pediatric PAC health care delivery. Leaders from 26 (54%) PAC facilities in 16 U.S. states completed the survey. Fifty-four percent identified as skilled nursing facility/long-term care, 19% intermediate care facilities, 15% respite and medical group homes, and 12% post-acute rehabilitation facilities. Sixty-nine percent of facilities had a significant increase in the medical complexity of patients over the past 10 years. Most reported capability to care for children with tracheostomy/invasive ventilation (100%), gastrostomy tubes (96%), intrathecal baclofen pump (89%), non-invasive positive pressure ventilation (85%), and other medical technology. Most facilities (72%) turned away patients for admission due to bed unavailability occasionally or always. Most facilities (62%) reported that insurance reimbursement to cover the cost of providing PAC to children was not acceptable, and most reported that it was difficult to hire clinical staff (77%) and retain staff (58%). PAC in the U.S. is provided to an increasingly medically-complex population of children. There is a critical need to investigate financially-viable solutions for PAC facilities to meet the patient demands for their services and to sufficiently reimburse and retain staff for the challenging and important care that they provide.

A Good Time to Be Born

A Good Time to Be Born

Types of Attractive Dosage Forms for Primary School Students and Associated Factors in Baghdad/ Iraq

The lack of age-appropriate and child -friendly formulation of medication for children poses a major challenge to pediatric therapeutic practice, adherence, and health care delivery worldwide, however, formulation acceptability and preferences facilitate medication
 
 adherence in children, and they are important factors in achieving the intended treatment outcomes in which this study looks ahead. The present study aims to determine the various medication trends of children through their parents and caregivers, child preference of certain dosage form (chewable gel) in comparison with another solid dosage forms and its popularity among Iraqi primary school, furthermore the study highlights different variables influence student preference for chewable gel. A total of 230 Iraqi primary school students were randomly selected and interviewed with the presence of their parents. It was observed that (51.3%) of the parents/caregivers reported that the liquid dosage form is the most dosage form that commonly used, (72%) of consumers revealed that the capsules and tablets are not easy to swallow, furthermore, this study revealed that (68.6%) of school students preferred to take medication as chewable gel over than other oral solid dosage forms ,and this preference varied significantly with several socioeconomic and other factors.

Pediatric Primary Health Care: The Central Role of Pediatricians in Maintaining Children's Health in Evolving Health Care Models.

Pediatric primary health care (PPHC) is of principal importance to the health and development of all children, helping them reach their true potential. Pediatricians, as the clinicians most intensively trained and experienced in child health, are the natural leaders of PPHC within the context of the medical home. Given the rapidly evolving models of pediatric health care delivery, including the explosion of telehealth in the wake of the COVID-19 pandemic, pediatricians, together with their representative national organizations such as the American Academy of Pediatrics (AAP), are the most capable clinicians to guide policy innovations on both the local and national stage.

Paediatric Nurses Approach in Carrying Out Patient and Family Centered Care at a Tertiary Hospital in Northern Ghana

Background: Patient and Family Centred Care (PFCC) is one of the fundamentals in paediatrics nursing which is struggling to gain recognition in nursing practice worldwide due to inadequate exploratory studies in the area. Others also call PFCC in paediatric world as Child and Family Centred Care (CFCC). Admittedly, its benefits to paediatric health care delivery cannot be measured but practicing is problematic. Nurses, policy makers and nursing research are yet to give the necessary attention PFCC deserves.
 Purpose: The purpose of this study was therefore to explore the practice of PFCC in the Paediatric Ward of Tamale Teaching Hospital.
 Methodology: This study made use of a purposive convenient design. Qualitative data was collected using validated interview guide which were administered to ten participants in the Paediatric Ward of Tamale Teaching Hospital in the Tamale Metropolis.
 Key Findings: The results showed majority of the participants do not have enough knowledge on PFCC, PFCC is partially being practiced and inadequate infrastructural in the ward.
 Recommendations: Policy on PFCC should be established by the government, models of Patient and Family Centred Care should be developed, refresher courses on PFCC should be given to nurses, the general public should be sensitized on PFCC and more nursing research should be carried on it.

88 Family Absence at the Bedside during the COVID-19 Pandemic

Primary Subject areaHospital PaediatricsBackgroundChild and family-centered care, a partnership approach to health care decision-making, is central to paediatric practice. To reduce transmission of SARS-CoV-2, healthcare institutions implemented policies to protect staff, patients and families. Family presence at the bedside was reduced to one caregiver, except in special circumstances requiring pre-approval by hospital leadership.ObjectivesWe explored the impact of the COVID-19 pandemic on paediatric healthcare delivery, focusing on family presence. We describe the clinician's experience of restricted family presence during the COVID-19 pandemic in a paediatric hospital.Design/MethodsPhysicians, trainees, and nurses at The Hospital for Sick Children completed surveys between March-August 2020 to identify patients they perceived to have experienced a suboptimal quality of care or health-outcome related to changes that had occurred as a result of the pandemic and describe the impact. Data were analyzed via case report and thematic analysis. As part of a larger study, here we report on cases related to family presence in the hospital.ResultsA total of 212 clinicians reported 116 cases; eighteen cases specified an impact on child and family-centered care. Nine cases related to patient experiences and nine to family experiences of the restricted family presence policy. Clinicians reported a perceived distress in patients due to family members not being present. 6267 family restriction exemption requests were received. Cases described families who opted for a different location for end-of-life care so that extended family could be present. Further cases highlighted how important conversations such as disclosure of diagnosis involved one parent present and the other joining remotely. Siblings were also reported to be impacted by visitor restrictions and closure of the sibling play area. Exclusions were also reported to be challenging for children with complex medical needs and technology dependency whereby two-caregivers were often required. Clinicians reported experiencing stress and moral distress as part of being required to support family restriction policies, impairing their ability to provide care.ConclusionFamily presence policies are a critical component of child and family-centered care and have been impacted by the pandemic as described both by family and clinician stress. Recommendations based on these findings would include: facilitating two-caregiver presence to support shared decision making, regular remote meetings to communicate information with families in cases where they cannot be physically present; using remote technology or implementing allotted visitation time for siblings, reviewing exceptions to caregiver restrictions, and mental health supports for clinicians such as peer-support groups, or wellness workshops.

Factors Influencing the Acceptance of Pediatric Telemedicine Services in China: A Cross-Sectional Study.

Background: Pediatrician workforce shortages have aroused great attention from health authorities in China. Telemedicine services have been known to enhance the management of children's health, yet the rate of adoption and usage in Chinese hospitals still at a quite low level, and the factors influencing the acceptance of telemedicine services remains unclear.Objective: The purpose of this empirical study was to evaluate the reliability and validity of a technology acceptance measurement instrument applied in healthcare, to investigate the perception of telemedicine services on the provider-side and demand-side, and to determine the factors that may drive individuals to adopt telemedicine services.Methods: A cross-sectional survey study based at Shanghai Children's Hospital, Shanghai Jiao Tong University, was conducted in March 2020. A total of 456 valid responses were obtained by convenience sampling. The internal consistency of items was assessed by Cronbach's alpha (α), composite reliability (CR) and average variance extracted (AVE) to evaluate both the reliability and validity of the questionnaire. Structural equation modeling analysis was used to test and verify the interrelationships among relevant variables.Results: Price value is the strongest predictor (β = 0.30, p = 0.02), facilitating conditions (β = 0.28, p = 0.01) and hedonic motivation (β = 0.13, p = 0.04) also have significantly positive direct effects on telemedicine acceptance. The results showed the perception of child patients' families were significantly more acceptable to telemedicine services than pediatricians (t = −2.99, p < 0.01). Participants with no prior experience and lower education may be more willing to adopt telemedicine.Conclusion: Telemedicine will likely continue to have an integral role in pediatric health care delivery, and the findings can assist policy makers and hospital administrators in determining the more valued characteristics of telemedicine services from a behavioral perspective. Future attention will be paid to the pricing, training and service quality of telemedicine in China.

SPN 2021 Poster Abstract Awards

SPN 2021 Poster Abstract Awards

Changes in Pediatric Hospital Care during the COVID‐19 Pandemic: A National Qualitative Study

Research ObjectiveThe COVID‐19 pandemic has necessitated rapid changes in healthcare delivery in the United States, including changes in the care of hospitalized children. This study aims to identify major changes in inpatient pediatric healthcare delivery and potential lessons learned.Study DesignIn this study, we conducted semi‐structured video interviews. We analyzed interview data using constant comparative methods to identify major healthcare delivery changes for hospitalized children during the COVID‐19 pandemic.Population StudiedWe purposefully sampled clinicians from both community and children's hospitals serving pediatric patients in the 6 U.S. states with the highest COVID‐19 hospitalization rates at the onset of the pandemic (NY, NJ, DC, MA, CT, LA). We recruited 2 participants from each hospital to interview (mix of administrators, physicians, and nurses).Principal FindingsWe interviewed 24 participants from 12 hospitals and identified several themes [Table 1]. They described how hospital leaders rapidly developed policies to: 1) ensure adequate staff for surges of COVID‐19 patients, 2) provide adequate care spaces and supplies, 3) direct use of personal protective equipment, and 4) guide medical management of COVID‐19 patients. Hospital leaders optimized communication by conducting regular meetings to discuss the current state of the pandemic, hospital operations, and policy changes. In the setting of declining volumes of hospitalized children, clinicians newly provided care for hospitalized adults. This was facilitated by developing care teams supported by adult hospitalists, educational resources, and telehealth supports. Participants described negative impacts of the pandemic on clinicians' mental health, as well as helpful supports for clinician well‐being, including mental health resources, wellness activities and spaces, and housing. Finally, participants described experiences managing multisystem inflammatory syndrome in children including diagnostic uncertainty and evolving management for this novel disease.TABLE 1 ThemeExemplary QuoteDeveloping and evolving COVID‐related hospital policies“We have eight separate COVID related pathways. One for outpatient, one for ED, one for inpatient, and one for therapeutics. Pretty rigorous.”Successful communication with clinicians and staff“One of the things that went really well was… daily town halls and transparency for the rapidly evolving situation.”Newly providing care for hospitalized adults“They had what they called a super hospitalist, who was an adult hospitalist who would oversee…five or six different [mixed specialty care] teams and help out with some of the decision making.”Organizing spaces for COVID‐19 patient care“As [the only freestanding] children's hospital [in the city], our role ended up being kind of a referral center for all the other centers to offload their pediatric patients.”ConclusionsWe identified several changes in inpatient pediatric care delivery and potential lessons learned during the COVID‐19 pandemic: 1) optimizing communication aided in rapidly changing hospital policies, 2) developing new team models and educational resources helped clinicians in newly caring for hospitalized adults, and 3) providing wellness resources was helpful for supporting clinicians' mental health.Implications for Policy or PracticeThis study's findings will assist hospital leaders to plan for safe and high‐quality care for hospitalized children, in this ongoing pandemic and in future disaster planning.Primary Funding SourceAgency for Healthcare Research and Quality.

Trauma-Informed Care in Child Health Systems.

Trauma-Informed Care in Child Health Systems.

Psychometric Testing of Family Centered Care (FCC) Instrument: A Mixed Methods Analysis of Pediatric Nurses and Their Workplace Perceptions of FCC

Background/purposeFamily-Centered care (FCC) is a model used in pediatric healthcare delivery wherein planning care for children incorporates the family, but questions remain whether there has been effective FCC implementation in practice. The purpose of this study was to examine the importance of FCC to pediatric nurses and their view of their organizations' support of FCC implementation. MethodA survey with FCC descriptor statements was distributed electronically to the Society of Pediatric Nurses. Direct care nurses (N = 132) responded to demographic questions including their education level and organization size, and 26 items rating the importance of elements of FCC in their care (as it applies to themselves) and in their organizations (as it applies to their hospital or organization) using a 5-point Likert scale. Open ended questions supplemented the survey to yield narrative comments to triangulate the findings. ResultsThe nurses' personal responses and their rating of their organizations were analyzed separately. The Cronbach alphas were 0.867 and 0.938, respectively. Factor analyses revealed the same three factors in the two foci of questions for (a) the nurse's own practice and (b) the organization's support of FCC: Philosophy of FCC, Implementation of FCC and Environment Variations of FCC. A qualitative process of narrative analysis added support to the factors with clarity in thematic triangulation. Additionally, there was a significant difference in the mean scores between nurses' personal responses and the mean scores for their organizations for all three factors (p = .000) and for self-reported FCC by nursing education to validate the utility of the tool. ConclusionsThis instrument quantified the importance of FCC to pediatric nurses and their workplace support of FCC and can be used in future studies to evaluate FCC.

Data Disaggregation: A Research Tool to Identify Health Inequities

The U.S. population is increasingly diverse, with less than half of all children identifying as non-Hispanic White. It is imperative health care providers and researchers further their awareness of how race and structural racism contribute to pervasive, systemic health disparities among children and their families so that steps can be taken to alleviate health inequities. This paper examines data disaggregation, on the basis of race and ethnicity, as a research tool to examine the heterogeneity of the pediatric population, identifies strategies for conducting research with disaggregated data, and provides examples of research in which data disaggregation has increased knowledge of racial and ethnic inequities in pediatric health and health care delivery.

Development of an international standard set of patient-centred outcome measures for overall paediatric health: a consensus process

ObjectiveTo develop an Overall Pediatric Health Standard Set (OPH-SS) of outcome measures that captures what matters to young people and their families and recognising the biopsychosocial aspects of health for...

The Impact of COVID-19 on Pediatric Adherence and Self-Management.

The COVID-19 pandemic has presented unique circumstances that have the potential to both positively and negatively affect pediatric adherence and self-management in youth with chronic medical conditions. The following paper discusses how these circumstances (e.g., stay-at-home orders, school closures, changes in pediatric healthcare delivery) impact disease management at the individual, family, community, and healthcare system levels. We also discuss how barriers to pediatric adherence and self-management exacerbated by the pandemic may disproportionately affect underserved and vulnerable populations, potentially resulting in greater health disparities. Given the potential for widespread challenges to pediatric disease management during the pandemic, ongoing monitoring and promotion of adherence and self-management is critical. Technology offers several opportunities for this via telemedicine, electronic monitoring, and mobile apps. Moreover, pediatric psychologists are uniquely equipped to develop and implement adherence-promotion efforts to support youth and their families in achieving and sustaining optimal disease management as the current public health situation continues to evolve. Research efforts addressing the short- and long-term impact of the pandemic on pediatric adherence and self-management are needed to identify both risk and resilience factors affecting disease management and subsequent health outcomes during this unprecedented time.

Pediatric Asthma Health Care Utilization, Viral Testing, and Air Pollution Changes During the COVID-19 Pandemic

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic caused dramatic changes in daily routines and health care utilization and delivery patterns in the United States. Understanding the influence of these changes and associated public health interventions on asthma care is important to determine effects on patient outcomes and identify measures that will ensure optimal future health care delivery.ObjectiveWe sought to identify changes in pediatric asthma-related health care utilization, respiratory viral testing, and air pollution during the COVID-19 pandemic.MethodsFor the time period January 17 to May 17, 2015 to 2020, asthma-related encounters and weekly summaries of respiratory viral testing data were extracted from Children's Hospital of Philadelphia electronic health records, and pollution data for 4 criteria air pollutants were extracted from AirNow. Changes in encounter characteristics, viral testing patterns, and air pollution before and after Mar 17, 2020, the date public health interventions to limit viral transmission were enacted in Philadelphia, were assessed and compared with data from 2015 to 2019 as a historical reference.ResultsAfter March 17, 2020, in-person asthma encounters decreased by 87% (outpatient) and 84% (emergency + inpatient). Video telemedicine, which was not previously available, became the most highly used asthma encounter modality (61% of all visits), and telephone encounters increased by 19%. Concurrently, asthma-related systemic steroid prescriptions and frequency of rhinovirus test positivity decreased, although air pollution levels did not substantially change, compared with historical trends.ConclusionsThe COVID-19 pandemic in Philadelphia was accompanied by changes in pediatric asthma health care delivery patterns, including reduced admissions and systemic steroid prescriptions. Reduced rhinovirus infections may have contributed to these patterns.

Building a Children\u2019s Health Service and System Research Strategy: development and integration in an Australian paediatric healthcare setting

BackgroundHealth services and systems research (HSSR) strategies dedicated to paediatric health care and service delivery are limited. Strategies are available but are outdated and yet to be optimised for use in a paediatric health system. We aim to describe the development and integration of a Children’s Health Service and System Research Strategy (CHSSR-S) in Children’s Health Queensland (CHQ), a large specialist quaternary hospital and health service caring for children and young people in Queensland and northern New South Wales, Australia.MethodsThe CHSSR-S was developed using an inductive, bottom-up, participatory systems approach across three phases: (1) Identifying local HSSR capacity; (2) Development; (3) Integration. A HSSR “Champion” was appointed to lead all phases. Clinical, research and system-based stakeholders (n = 14) were individually identified, contacted and participated in dedicated meetings and a workshop to iteratively design the CHSSR-S. A health system-wide CHSSR-S governance committee was established to drive phase three. Health system integration was achieved by multicomponent, action-based strategies.ResultsThe final CHSSR-S comprised ten Research Priorities and three Research Enablers, and was successfully integrated within CHQ via a range of platforms. Research Priorities included: (1) Population Health; (2) Adolescent and Young Adult (AYA) Cancer; (3) Indigenous Health; (4); Mental Health; (5) Nutrition and Obesity; (6) Rare Neurodevelopmental Disorders; (7) Sepsis; (8) Screening, surveillance and monitoring; (9) Innovation; and (10) Electronic Medical Record (EMR). Research Priorities were supported by three Research Enablers: (1) Data; (2); Evaluation and Health Economics; and (3) Policy.ConclusionsThe CHSSR-S is the first known paediatric HSSR strategy developed and integrated within a large dedicated paediatric health system. The CHSSR-S may be used to guide global paediatric healthcare systems to prioritise HSSR in their local setting to optimise health service delivery and patient outcomes.