Pediatric psychoSocial Risk Index: Factor Analysis and Item Reduction Study.

OBJECTIVES: The Pediatric psychoSocial Risk Index (PSRI) is psychosocial risk screening instrument for health practitioners. The objective of this study was to confirm validity evidence of a truncated version of PSRI. METHODS: PSRI was completed initially by 100 parents of children aged 0 to 18 years admitted to a tertiary hospital; 50 parents repeated the PSRI 3 days later. Analysis includes principal component analysis (PCA) to include the least number of items that explain the most variance in a shortened version of PSRI as well as confirming test-retest reliability and internal consistency of the shortened instrument. RESULTS: PSRI originally had 86 items, 85 close-ended items were analyzed. Three items were excluded because of missing test-retest data. Item reduction resulted in truncation of 16 items; 66 items remained. A Kaiser-Mayer-Orkin test of sampling adequacy resulted in reduction of 14 items; 52 items remained. Initial PCA led to reduction of 26 items. The PCA was rerun on remaining items, resulting in reduction of 6 further items; 18 items remained. Two items with >10% missingness were removed leaving 16 items in the final PSRI. Test-retest reliability was 0.98 and mean within-person across-item reliability was 0.95. Cronbach α was 0.9. Remaining items represented 9 social risk themes: food insecurity, medical complexity, home environment, behavioral issues, financial insecurity, parenting confidence, parental mental health, social support, and unmet medical needs. CONCLUSIONS: PSRI was reduced from 86 to 16 items with high internal consistency and reliability. PSRI demonstrates adequate validity supporting practitioners to screen families about their psychosocial risk.

Swish and gargle saliva sampling is a patient-friendly and comparable alternative to nasopharyngeal swabs to detect SARS-CoV-2 in outpatient settings for adults and children.

IMPORTANCE: Widespread and frequent testing for COVID-19 was an important strategy to identify infected patients to isolate and control the spread of the disease during the pandemic. The nasopharyngeal swab (NPS) global supply chain and access to trained healthcare professionals for standard NPS collection were often compromised. Patient discomfort and limited access challenged health systems to reach large numbers for testing in adult and pediatric populations. Our study revealed that swish and gargle saliva (SGS) was comparable to NPS in detecting SARS-CoV-2 and more patient-friendly than NPS. Patients were more likely to repeat the test with SGS. SGS was amenable to self-collection instead of relying on skilled professionals. This comprehensive evaluation highlights the challenges of comparing the accuracy of new methods to imperfect gold standards and identifies additional patient-centric factors that should be considered when defining such standards. Thus, SGS is an advantageous alternative specimen collection for outpatient en masse testing.

Mental Health Trajectories of Children and Caregivers Using School-Based Health Centers During the COVID-19 Pandemic.

INTRODUCTION: This was a prospective study of children registered at school-based health centers (SBHCs) in Canada. The objectives were to compare mental health trajectories of children and parents/caregivers who accessed SBHCs during the pandemic relative to those who did not. METHOD: Parents/caregivers of children who attended SBHCs completed the Strengths and Difficulties Questionnaire (SDQ) and the Generalized Anxiety Disorder-7 (GAD-7) at three time points during the pandemic. The primary analysis used linear mixed models to examine the relationship between SBHC visits during the pandemic and children's SDQ score trajectories. The secondary analysis was the same for parents'/caregivers' GAD-7 scores. RESULTS: There were 435 children included. SDQ and GAD-7 scores worsened over time for children and parents/caregivers who attended SBHCs during the pandemic compared to those who did not. DISCUSSION: Children and parents/caregivers with worsening mental health symptoms may have sought care at SBHCs since they were accessible during the pandemic.

Pediatric School Outreach: Clinical Needs of an Urban Student Population.

Pediatric School Outreach (PSO) is a school-based health center (SBHC) in an urban elementary school in Toronto, Canada. PSO focuses on developmental, behavioral, mental health, and educational concerns. A retrospective chart review aimed to characterize demographics, diagnoses, and referrals of patients attending PSO. Of 137 children, ages 2 to 15 years, 73.7% were male; 58.1% had a household annual income of <$30 000 CAD. Possible or confirmed diagnoses included attention deficit hyperactivity disorder (48.5%), learning disability (35.6%), anxiety (22.0%), autism spectrum disorder (16.7%), oppositional defiant disorder (14.4%), and expressive language delay (11.4%). Involvement of community mental health and other agencies was advised in 37.9% of cases. Psychoeducational testing was recommended for 25.0% of patients. Results suggest the need for timely developmental testing, particularly for autism spectrum disorder, and accessible learning disability diagnostic support. There is potential for expansion of interprofessional care at PSO, including psychology, psychiatry, social work, and behavior therapy.

Patient- and Family-Centered Care in the Emergency Department for Children With Autism.

BACKGROUND: Emergency department (ED) care processes and environments impose unique challenges for children with autism spectrum disorder (ASD). The implementation of patient- and family-centered care (PFCC) emerges as a priority for optimizing ED care. In this article, as part of a larger study, we explore PFCC in the context of ASD. Our aims were to examine how elements of PFCC were experienced and applied relative to ED care for children with ASD. METHODS: Qualitative interviews were conducted with parents and ED service providers, drawing on a grounded theory approach. Interviews were audio recorded, transcribed verbatim, and analyzed by using established constant comparison methods. Data were reviewed to appraise the reported presence or absence of PFCC components. RESULTS: Fifty-three stakeholders (31 parents of children with ASD and 22 ED service providers) participated in interviews. Results revealed the value of PFCC in autism-based ED care. Helpful attributes of care were a person-centered approach, staff knowledge about ASD, consultation with parents, and a child-focused environment. Conversely, a lack of staff knowledge and/or experience in ASD, inattention to parent expertise, insufficient communication, insufficient family orientation to the ED, an inaccessible environment, insufficient support, a lack of resources, and system rigidities were identified to impede the experience of care. CONCLUSIONS: Findings amplify PFCC as integral to effectively serving children with ASD and their families in the ED. Resources that specifically nurture PFCC emerge as practice and program priorities.

Development of the Pediatric Social Risk Instrument Using a Structured Panel Approach.

BACKGROUND: Social determinants of health impact child illness. Currently, no instrument exists to identify social need during hospital admission. METHODS: Using the UCLA (University of California Los Angeles)-RAND appropriateness method, consensus was reached for an instrument to identify social need in hospitalized children. A panel of 11 experts reviewed candidate indicators through 3 rounds to reach consensus. The instrument then underwent usability testing. RESULTS: Three hundred and forty-seven indicators from the literature were sorted into 18 social risk themes. After 3 rounds, consensus was reached on 82 indicators. Six additional social risk themes were recommended by the panel, resulting in consensus for 18 additional indicators. Final refinement resulted in an instrument containing 86 indicators representing 11 social risk themes. Usability testing identified that the tool was well received by families. Final feedback was incorporated into a post-usability instrument. CONCLUSIONS: Using the UCLA-RAND appropriateness method, a new pediatric social risk instrument was created to identify social need for hospitalized children.

Family fIRST, an Interactive Risk Screening Tool for Families in a School-Based Pediatric Clinic.

The purpose of this study was to create a tablet-based, social history screening tool called Family fIRST and evaluate its feasibility and usability in a school-based medical clinic. A mixed methods study design was used to examine quantitative and qualitative outcomes of a survey and semi-structured interview completed by families and physicians. The majority (87%) found the survey easy to understand. Themes for improvement included more free-form space and increased sensitivity around question wording. Clinic physicians felt Family fIRST increased discussion around social history and suggested the tool should help link to suggested resources. Demographic results showed that 12 of 29 (43%) parents had income less than $15 000 and 19 of 29 (65%) were unemployed. Family fIRST was a well-received and feasible tool to implement at the school-based medical clinic. Preliminary results show that families attending the clinic have increased prevalence of negative determinants of health; social history should therefore represent a key area of focus at the medical visit in order to optimize clinic support of families.

Experiences of emergency department care from the perspective of families in which a child has autism spectrum disorder.

Care for children with autism spectrum disorder (ASD) in the emergency department (ED) is increasingly recognized as difficult. Communication, sensory and behavioral challenges in a high intensity environment pose risks for negative experiences and outcomes. Through semi-structured interviews, parents (n = 31) and their children (n = 4) with ASD shared their perspectives on ED care. Participants identified issues that negatively affected care experiences, including care processes, communication issues, insufficient staff knowledge about ASD, and inadequate partnership with parents. Elements contributing to an improved ED experience were also cited, including staff knowledge about ASD, child- and family-centered care, and clarity of communication. Findings inform an emerging model of ED care. Recommendations for capacity building and practice development are offered.

Parent and health care provider perspectives related to disclosure of autism spectrum disorder in pediatric emergency departments.

Children and youth with autism spectrum disorder presenting in emergency departments face potential cognitive, sensory, and behavioral challenges, and it is crucial for providers to be aware of their unique needs. However, disclosure of a child's autism spectrum disorder can be complex for parental caregivers and is not well understood. This qualitative study utilized a grounded theory approach and analyzed data from 28 parents and 16 health care providers related to autism spectrum disorder disclosure within two Canadian pediatric emergency departments. Study results indicated that participants identified benefits and risks of disclosure. Encouraging understanding, expediting service, and preparing health care providers for working with children with autism spectrum disorder were identified as benefits of disclosure. Risks related to disclosure included potential negative attributions toward the children and parental discomfort in disclosing a diagnosis in front of the children. Parents discussed the health care encounters they experienced following disclosure and provided recommendations for improving the disclosure process in the emergency department. It is recommended that future research explore the experiences of parents who choose not to disclose their child's autism spectrum disorder. Greater awareness of the disclosure experience and the development of resources and tools to support communication between parents and health care providers are also recommended.

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

BACKGROUND AND OBJECTIVE: 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. METHODS: 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. RESULTS: 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.

Perspectives of Health Care Providers Regarding Emergency Department Care of Children and Youth with Autism Spectrum Disorder.

This study aimed to characterize the perspectives of health professionals who care for children with autism spectrum disorder (ASD) in the emergency department (ED) and to determine what strategies could optimize care. Ten physicians and twelve nurses were interviewed individually. Questions related to experiences, processes, clinical decision-making and outcomes of children with ASD recently seen in the ED. Interviews were audio recorded, transcribed, and analyzed using a qualitative framework. Participants identified factors that facilitated effective care, including communication strategies, parental involvement and teamwork. Barriers identified included child characteristics, the ED environment, and competing demands. Recommendations included additional staff training and stakeholder engagement. However, making accommodations was often described as being at odds with how the ED functioned, with implications for future service planning.

Autism in the emergency department.

BACKGROUND: This is a retrospective chart review of autistic patients presenting to the emergency department (ED) in a tertiary care pediatric center during the year 2011. RESULTS: There were 160 ED visits by 130 patients, 25% of visits were repeated, and 20% were admitted to the hospital. There were 126 (79%) male and 34 (21%) female patients mean age of 12 years, 79% had comorbid health conditions. Forty percent were CTAS 2 (Canadian Triage Acuity Score) acuity, 42% of visits were CTAS 3 acuity, and 7% rated their pain as "severe." Visits were for behavior (10%), neurological concern (13%), 3% dental related, and the remainder were for gastrointestinal infections and other complaints. Average length of stay was 6 hours 21 minutes, with 2-hour wait to start assessment with physician. CONCLUSIONS: Autism is a prevalent diagnosis and patients with autism are accessing the ED. We hope to use these demographic findings to better serve these patients and their families.

Pandemic management in a pediatric hospital.

OBJECTIVES: To describe our experiences in the management of the second wave of influenza A H1N1 (pH1N1) pandemic in a tertiary-care children's hospital. METHODS: An autoethnographic study of the pandemic planning and management committee members involved in managing the second wave of pH1N1 was conducted. RESULTS: Staffing, surge capacity, communications and emergency operations planning by adding leaders of frontline workers and other key operational roles to the incident management team, and creating a tactical response team emerged as important factors in pandemic management in our hospital. The emergency department visits increased by 50%, necessitating increased staffing of the emergency department. Communications using existing chains of command had to be used to reach frontline staff during the pandemic. CONCLUSIONS: Incident management teams managing pandemics and other disasters have to be dynamic and create tactical teams to ensure implementation and facilitate bidirectional communication with frontline workers.

Charting errors in a teaching hospital.

OBJECTIVE: The objective of this study was to assess charting errors by junior trainees in the emergency department at the beginning of the academic year and to evaluate the effect of audits and reminders in reducing charting errors in July. METHODS: Medical records from June and July 2006 were reviewed to identify incomplete documentations (charting errors) in 5 areas. The audit was repeated in July 2007 after sample charts were displayed, and reminders were sent. RESULTS: There were 129 patient records completed by 12 trainees in June 2006 and 122 by 11 trainees in July 2006. The mean charting error rate for July (24%) was significantly higher than that in June (17%) (P = 0.0041). The mean charting error rate reduced to 14% after the intervention in July 2007. CONCLUSIONS: There is a significant increase in charting errors by new trainees in July compared with June. A simple intervention of reminders and alerts significantly reduced charting errors in July.

Management of infantile colic: a review.

Infantile colic is an easily identified childhood entity that has no clear treatment guidelines. The management of infantile colic varies among physicians, and families are often frustrated by the medical community's inability to prescribe a cure for colic. This article reviews the current concepts for management options of infantile colic.