A randomized trial of iPad distraction to reduce children's pain and distress during intravenous cannulation in the paediatric emergency department.

OBJECTIVES: We compared the addition of iPad distraction to standard care, versus standard care alone, to manage the pain and distress of intravenous (IV) cannulation. METHODS: Eighty-five children aged 6 to 11 years requiring IV cannulation (without child life services present) were recruited for a randomized controlled trial from a paediatric emergency department. Primary outcomes were self-reported pain (Faces Pain Scale-Revised [FPS-R]) and distress (Observational Scale of Behavioral Distress-Revised [OSBD-R]), analyzed with two-sample t-tests, Mann-Whitney U-tests, and regression analysis. RESULTS: Forty-two children received iPad distraction and 43 standard care; forty (95%) and 35 (81%) received topical anesthesia, respectively (P=0.09). There was no significant difference in procedural pain using an iPad (median [interquartile range]: 2.0 [0.0, 6.0]) in addition to standard care (2.0 [2.0, 6.0]) (P=0.35). There was no significant change from baseline behavioural distress using an iPad (mean ± SD: 0.53 ± 1.19) in addition to standard care (0.43 ± 1.56) (P=0.44). Less total behavioural distress was associated with having prior emergency department visits (odds ratio [95% confidence interval]: -1.90 [-3.37, -0.43]) or being discharged home (-1.78 [-3.04, -0.52]); prior hospitalization was associated with greater distress (1.29 [0.09, 2.49]). Significantly more parents wished to have the same approach in the future in the iPad arm (41 of 41, 100%) compared to standard care (36 of 42, 86%) (P=0.03). CONCLUSIONS: iPad distraction during IV cannulation in school-aged children was not associated with less pain or distress than standard care alone. The effects of iPad distraction may have been blunted by topical anesthetic cream usage. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov: NCT02326623.

What are the care needs of families experiencing cardiac arrest?: A survivor and family led scoping review.

AIM: The sudden and unexpected cardiac arrest of a family member can be a grief-filled and life-altering event. Every year many hundreds of thousands of families experience the cardiac arrest of a family member. However, care of the family during the cardiac arrest and afteris poorly understood and incompletely described. This review has been performed with persons with lived experience of cardiac arrest to describe, "What are the needs of families experiencing cardiac arrest?" from the moment of collapse until the outcome is known. METHODS: This review was guided by specific methodological framework and reporting items (PRISMA-ScR) as well as best practices in patient and public involvement in research and reporting (GRIPP2). A search strategy was developed for eight online databases and a grey literature review. Two reviewers independently assessed all articles for inclusion and extracted relevant study information. RESULTS: We included 47 articles examining the experience and care needs of families experiencing cardiac arrest of a family member. Forty one articles were analysed as six represented duplicate data. Ten family care need themes were identified across five domains. The domains and themes transcended cardiac arrest setting, aetiology, family-member age and family composition. The five domains were i) focus on the family member in cardiac arrest, ii) collaboration of the resuscitation team and family, iii) consideration of family context, iv) family post-resuscitation needs, and v) dedicated policies and procedures. We propose a conceptual model of family centred cardiac arrest. CONCLUSION: Our review provides a comprehensive mapping and description of the experience of families and their care needs during the cardiac arrest of a family-member. Furthermore, our review was conducted with co-investigators and collaborators with lived experience of cardiac arrest (survivors and family members of survivors and non-survivors alike). The conceptual framework of family centred cardiac arrest care presented may aid resuscitation scientists and providers in adopting greater family centeredness to their work.

A randomized trial of robot-based distraction to reduce children's distress and pain during intravenous insertion in the emergency department.

OBJECTIVES: Our objectives were to evaluate the effectiveness of humanoid robot-based distraction on reducing distress and pain in children undergoing intravenous insertion. METHODS: A two-arm, open-label randomized controlled trial was conducted April 2017-May 2018, in a pediatric emergency department (ED). A sample of 86 children aged 6-11 years who required intravenous insertion were recruited. Exclusion criteria included hearing/visual impairments, neurocognitive delay, sensory impairment to pain, previous enrollment, and ED clinical staff discretion. Outcome measures included the Observed Scale of Behavioral Distress-Revised (OSBD-R) (distress) and the Faces Pain Scale-Revised (FPS-R) (pain). RESULTS: Of the 86 children recruited (median age 9 years, IQR 7,10); 55% (47/86) were male, 9% (7/82) were premature, 82% (67/82) had a previous ED visit, 31% (25/82) had a previous hospitalization and 78% (64/82) had previous intravenous insertion. Ninety-six percent (78/81) received topical anesthetic prior to intravenous insertion. Total OSBD-R distress score was 1.49 ± 2.36 (standard care) versus 0.78 ± 1.32 (robot) (p < 0.05). FPS-R pain score was 4 (IQR 2,6) (standard care) versus 2 (IQR 0,4) (robot) (p = 0.13). Parental anxiety immediately after the procedure was 36.7 (11.1) (standard care) versus 31.3 (8.5) (robot) (p = 0.04). Parents were more satisfied with pain management in the robotic distraction group (95% vs 72% very satisfied) (p = 0.002). CONCLUSIONS: Humanoid robot-based distraction therapy is associated with a modest positive impact on child distress for pediatric intravenous insertion, but not pain. It can be considered a potential tool in the ED toolkit for procedural pain-associated distress reduction. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02997631.

RéSUMé: OBJECTIFS: Nos objectifs étaient d'évaluer l'efficacité de la distraction robotique humanoïde pour réduire la détresse et la douleur chez les enfants subissant une insertion intraveineuse. MéTHODES: Un essai contrôlé randomisé ouvert à deux bras a été mené d'avril 2017 à mai 2018, dans un service d'urgence pédiatrique. Un échantillon de 86 enfants âgés de 6 à 11 ans ayant besoin d'une insertion intraveineuse a été recruté. Les critères d'exclusion comprenaient des déficiences auditives / visuelles, un retard neurocognitif, une déficience sensorielle de la douleur, une inscription antérieure et la discrétion du personnel clinique des urgences. Les mesures des résultats comprenaient l'échelle d'hétéro-évaluation comportementale (OSBD-R: Observational Scale of Behavioral Distress ­ Revised) (détresse) et l'échelle de visages (FPS-R: Faces Pain Scale-Revised) (douleur). RéSULTATS: Sur les 86 enfants recrutés (âge médian 9 ans, IQR 7,10) ; 55 % (47/86) étaient de sexe masculin, 9 % (7/82) étaient prématurés, 82 % (67/82) avaient une visite antérieure aux urgences, 31 % (25/82) avaient déjà été hospitalisés et 78 % (64/82) avaient déjà été insérés par voie intraveineuse. Quatre-vingt-seize pour cent (78/81) ont reçu une anesthésie topique avant l'insertion intraveineuse. Le score total de détresse OSBD-R était de 1,49 ± 2,36 (soins standard) contre 0,78 ± 1,32 (robot) (p < 0,05). Le score de douleur FPS-R était de 4 (IQR 2,6) (soins standard) contre 2 (IQR 0, 4) (robot) (p=0,13). L'anxiété parentale immédiatement après l'intervention était de 36,7 (11,1) (soins standard) contre 31,3 (8,5) (robot) (p=0,04). Les parents étaient plus satisfaits de la gestion de la douleur dans le groupe de distraction robotique (95 % vs 72 % très satisfaits) (p = 0,002). CONCLUSIONS: La thérapie de distraction à base de robot humanoïde est associée à un impact positif modeste sur la détresse de l'enfant pour l'insertion intraveineuse pédiatrique, mais pas la douleur. Il peut être considéré comme un outil potentiel dans la boîte à outils des Services d'Urgences pour la réduction de la détresse associée à la douleur procédurale.

Characterizing Pain in Children with Acute Gastroenteritis Who Present for Emergency Care.

OBJECTIVE: To characterize the pain experienced by children with acute gastroenteritis (AGE) in the 24 hours before emergency department (ED) presentation. Secondary objectives included characterizing ED pain, discharge recommendations, overall analgesic use, and factors that influenced analgesic use and pain severity. STUDY DESIGN: A prospective cohort was recruited from 2 pediatric EDs (December 2014 to September 2017). Eligibility criteria included <18 years of age, AGE (≥3 episodes of diarrhea or vomiting in the previous 24 hours), and symptom duration <7 days at presentation. RESULTS: We recruited 2136 patients, median age 20.8 months (IQR 10.4, 47.4) and 45.8% (979/2136) female. In the 24 hours before enrollment, most caregivers reported moderate (28.6% [610/2136, 95% CI 26.7-30.5]) or severe (46.2% [986/2136, CI 44.0-48.3]) pain for their child. In the ED, they reported moderate (31.1% [664/2136, 95% CI 29.1-33.1]) or severe ([26.7% [571/2136, 95% CI 24.9-28.7]) pain; analgesia was provided to 21.2% (452/2131). The most common analgesics used in the ED were acetaminophen and ibuprofen. At discharge, these were also most commonly recommended. Factors associated with greater analgesia use in the ED were high pain scores during the index visit, having a primary care physician, earlier presentation to emergency care, fewer diarrheal episodes, presence of fever, and hospitalization at index visit. CONCLUSIONS: Most caregivers of children presenting to the ED with AGE reported moderate or severe pain, both before and during their visit. Future research should focus on the development of effective, safe, and timely pain management plans.

Effects of a Web-Based Patient Portal on Patient Satisfaction and Missed Appointment Rates: Survey Study.

BACKGROUND: Although electronic medical record (EMR)-tethered patient portals are common in other countries, they are still emerging in Canada. OBJECTIVE: We aimed to report user satisfaction and the effects of a patient portal on medical appointment attendance in a Canadian cohort of patients within our publicly funded health care system. METHODS: Two surveys were deployed, via email, at 2 weeks and 6 months following the first recorded patient portal access. Database audits of visit attendance were used to supplement and cross reference survey data. RESULTS: Between January 2016 and July 2018, 4296 patients accessed the patient portal. During the study, 28% (957/3421) consented patient portal users responded to one or more semistructured electronic surveys. Of respondents, 93% (891/957) reported that the patient portal was easy to use, 51% (492/975) reported it saved time when scheduling an appointment, and 40% (382/957) reported that they had to repeat themselves less during appointments. Respondents reported patient portal-related changes in health system use, with 48% (462/957) reporting avoiding a clinic visit and 2.7% (26/957) avoiding an emergency department visit. Across 19,968 visits in clinics where the patient portal was introduced, missed appointments were recorded in 9.5% (858/9021) of non-patient portal user visits, compared with 4.5% (493/9021) for patient portal users, representing a 53% relative reduction in no-show rates. CONCLUSIONS: Early experience with an EMR-tethered patient portal showed strong reports of positive patient experience, a self-reported decrease in health system use, and a measured decrease in missed appointment rates. Implications on the expanded use of patient portals requires more quantitative and qualitative study in Canada.

Digital Technology Distraction for Acute Pain in Children: A Meta-analysis.

CONTEXT: Digital distraction is being integrated into pediatric pain care, but its efficacy is currently unknown. OBJECTIVE: To determine the effect of digital technology distraction on pain and distress in children experiencing acutely painful conditions or procedures. DATA SOURCES: Medline, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Institute of Electrical and Electronics Engineers Xplore, Ei Compendex, Web of Science, and gray literature sources. STUDY SELECTION: Quantitative studies of digital technology distraction for acutely painful conditions or procedures in children. DATA EXTRACTION: Performed by 1 reviewer with verification. Outcomes were child pain and distress. RESULTS: There were 106 studies (n = 7820) that reported on digital technology distractors (eg, virtual reality and video games) used during common procedures (eg, venipuncture, dental, and burn treatments). No studies reported on painful conditions. For painful procedures, digital distraction resulted in a modest but clinically important reduction in self-reported pain (standardized mean difference [SMD] -0.48; 95% confidence interval [CI] -0.66 to -0.29; 46 randomized controlled trials [RCTs]; n = 3200), observer-reported pain (SMD -0.68; 95% CI -0.91 to -0.45; 17 RCTs; n = 1199), behavioral pain (SMD -0.57; 95% CI -0.94 to -0.19; 19 RCTs; n = 1173), self-reported distress (SMD -0.49; 95% CI -0.70 to -0.27; 19 RCTs; n = 1818), observer-reported distress (SMD -0.47; 95% CI -0.77 to -0.17; 10 RCTs; n = 826), and behavioral distress (SMD -0.35; 95% CI -0.59 to -0.12; 17 RCTs; n = 1264) compared with usual care. LIMITATIONS: Few studies directly compared different distractors or provided subgroup data to inform applicability. CONCLUSIONS: Digital distraction provides modest pain and distress reduction for children undergoing painful procedures; its superiority over nondigital distractors is not established. Context, preferences, and availability should inform the choice of distractor.

High stakes and high emotions: providing safe care in Canadian emergency departments.

BACKGROUND: The high-paced, unpredictable environment of the emergency department (ED) contributes to errors in patient safety. The ED setting becomes even more challenging when dealing with critically ill patients, particularly with children, where variations in size, weight, and form present practical difficulties in many aspects of care. In this commentary, we will explore the impact of the health care providers' emotional reactions while caring for critically ill patients, and how this can be interpreted and addressed as a patient safety issue. DISCUSSION: ED health care providers encounter high-stakes, high-stress clinical scenarios, such as pediatric cardiac arrest or resuscitation. This health care providers' stress, and at times, distress, and its potential contribution to medical error, is underrepresented in the current medical literature. Most patient safety research is limited to error reporting systems, especially medication-related ones, an approach that ignores the effects of health care provider stress as a source of error, and limits our ability to learn from the event. Ways to mitigate this stress and avoid this type of patient safety concern might include simulation training for rare, high-acuity events, use of pre-determined clinical order sets, and post-event debriefing. CONCLUSION: While there are physiologic and anatomic differences that contribute to patient safety, we believe that they are insufficient to explain the need to address critical life-threatening event-related patient safety issues for both adults and, especially, children. Many factors make patient safety during critical medical events distinct from general patient safety issues, but it is, perhaps, this heightened high-stress, emotional climate that is the most distinct and important part of all. We believe that consideration of this concept is essential when discussing safety improvement in critical medical events.

How usability of a web-based clinical decision support system has the potential to contribute to adverse medical events.

INTRODUCTION: Clinical decision support systems (CDSS) have the potential to reduce adverse medical events, but improper design can introduce new forms of error. CDSS pertaining to community acquired pneumonia and neutropenic fever were studied to determine whether usability of the graphical user interface might contribute to potential adverse medical events. METHODS: Automated screen capture of 4 CDSS being used by volunteer emergency physicians was analyzed using structured methods. RESULTS: 422 events were recorded over 56 sessions. In total, 169 negative comments, 55 positive comments, 130 neutral comments, 21 application events, 34 problems, 6 slips, and 5 mistakes were identified. Three mistakes could have had life-threatening consequences. CONCLUSION: Evaluation of CDSS will be of utmost importance in the future with increasing use of electronic health records. Usability engineering principles can identify interface problems that may lead to potential medical adverse events, and should be incorporated early in the software design phase.

Development of a flexible healthcare form builder using Ruby on Rails.

A collaboratively maintained, centralized web-based clinical decision support system (CDSS) repository could lead to improved quality and standardization of care and decrease duplication of resources. Ruby on Rails (RoR) is an open source web application framework that enables rapid iterative development of database backed applications. We have created a prototype form building application in RoR that has the potential to create and maintain such a CDSS repository. Further study and refinement are required.

Assessing the sensibility of two clinical decision support systems.

Clinicians in Emergency Medicine (EM) are increasingly exposed to guidelines and treatment recommendations. To help access and recall these recommendations, electronic Clinical Decision Support Systems (CDSS) have been developed. This study examined the use and sensibility of two CDSS designed for emergency physicians. CDDS for community acquired pneumonia (CAP) and neutropenic fever (NF) were developed by multidisciplinary teams and have been accessed via an intranet-based homepage (eCPG) for several years. Sensibility is a term coined by Feinstein that describes common sense aspects of a survey instrument. It was modified by emergency researchers to include four main headings: (1) Appropriateness; (2) Objectivity; (3) Content; and (4) Discriminative Power. Sensibility surveys were developed using an iterative approach for both the CAP and NF CDSS and distributed to all 25 emergency physicians at one Canadian site. The overall response rate was 88%. Respondents were 88% male and 83% were less than 40; all were attending EM physicians with specialty designations. A number reported never having used the CAP (21%) or NF (33%) CDSS; 54% (CAP) and 21% (NF) of respondents had used the respective CDSS less than 10 times. Overall, both CDSS were rated highly by users with a mean response of 4.95 (SD 0.56) for CAP and 5.62 (SD 0.62) for NF on a seven-point Likert scale. The majority or respondents (CAP 59%, NF 80%) felt that the NF CDSS was more likely than the CAP CDSS to decrease the chances of making a medical error in medication dose, antibiotic choice or patient disposition (4.61 vs. 5.81, p=0.008). Despite being in place for several years, CDSS for CAP and NF are not used by all EM clinicians. Users were generally satisfied with the CDSS and felt that the NF was more likely than the CAP CDSS to decrease medical errors. Additional research is required to determine the barriers to CDSS use.

The assessment and management of tinea capitis in children.

Tinea capitis is an infection of the scalp and hair shaft caused by dermatophyte fungi. It is seen in all age groups, and the incidence seems to be on the rise in North America. Clinical diagnosis of tinea capitis can be challenging, as symptoms can vary from minimal pruritus with no hair loss, to severe tenderness, purulence, and permanent scarring in inflammatory kerion lesions. The diagnosis of tinea capitis must be confirmed in the laboratory by using fungal stains or obtaining cultures, since treatment may be prolonged with potential side effects. Systemic therapy is needed because topical antifungals cannot effectively penetrate the hair shaft to eradicate the infection. Oral griseofulvin remains the standard treatment agent, but terbinafine and itraconazole are also effective alternatives (although currently without Food and Drug Administration approval).

Decision support technology in knowledge translation.

Information technologies, and specifically clinical decision support systems (CDSSs), are tools that can support the process of knowledge translation in the delivery of emergency department (ED) care. It is essential that during the implementation process, careful consideration be given to the workflow and culture of the ED environment where the system is to be utilized. Despite significant literature addressing factors contributing to successful deployment of these systems, the process is frequently problematic. Careful research and analysis are essential to evaluate the impact of the CDSS on the delivery of ED care, its influence on the health care providers, and the impact of the CDSS on clinical decision-making processes and information behaviors. The logistical and educational implications of CDSSs in the ED must also be considered. The specialty of emergency medicine must actively collaborate with other stakeholders in the design, implementation, and evaluation of CDSSs that will be utilized during the delivery of care to our patients.