Implementing Electronic Discharge Communication Tools in Pediatric Emergency Departments: Multicountry, Cross-Sectional Readiness Survey of Nurses and Physicians.

BACKGROUND: Pediatric emergency departments (ED) in many countries are implementing electronic tools such as kiosks, mobile apps, and electronic patient portals, to improve the effectiveness of discharge communication. OBJECTIVE: This study aimed to survey nurse and physician readiness to adopt these tools. METHODS: An electronic, cross-sectional survey was distributed to a convenience sample of currently practicing ED nurses and physicians affiliated with national pediatric research organizations in Canada, Australia, and New Zealand. Survey development was informed by the nonadoption, abandonment, scale-up, spread, sustainability framework. Measures of central tendency, and parametric and nonparametric tests were used to describe and compare nurse and physician responses. RESULTS: Out of the 270 participants, the majority were physicians (61%, 164/270), female (65%, 176/270), and had 5 or more years of ED experience (76%, 205/270). There were high levels of consensus related to the value proposition of electronic discharge communication tools (EDCTs) with 82% (221/270) of them agreeing that they help parents and patients with comprehension and recall. Lower levels of consensus were observed for organizational factors with only 37% (100/270) agreeing that their staff is equipped to handle challenges with communication technologies. Nurses and physicians showed significant differences on 3 out of 21 readiness factors. Compared to physicians, nurses were significantly more likely to report that EDs have a responsibility to integrate EDCTs as part of a modern system (P<.001) and that policies are in place to guide safe and secure electronic communication (P=.02). Physicians were more likely to agree that using an EDCT would change their routine tasks (P=.04). One third (33%, 89/270) of participants indicated that they use or have used EDCT. CONCLUSIONS: Despite low levels of uptake, both nurses and physicians in multiple countries view EDCTs as a valuable support to families visiting pediatric ED. Leadership for technology change, unclear impact on workflow, and disparities in digital literacy skills require focused research effort.

Children, young people and parent engagement in health intervention design and implementation: A scoping review.

INTRODUCTION: Engaging children and young people (CYP) with and without their parents in health research has the potential to improve the development and implementation of health interventions. However, to our knowledge, the scope of engagement activities used with this population and barriers to their engagement is unknown. The objective of this review was to identify and describe CYP engagement with and without their parents in the development and/or implementation of health interventions. METHODS: This scoping review included any primary research studies reporting on engaging CYP, with or without parents, in the design and/or implementation of health interventions. Healthcare professionals had to be involved over the course of the study and the study had to take place in either community, primary or tertiary care settings. The following databases were searched in May 2017, May 2020 and June 2021: Medline (OVID), CINAHL (EBSCO) and Embase (Elsevier). Two independent reviewers screened titles, abstracts and full-text articles and used a previously piloted extraction form to extract and summarize information from the included articles. RESULTS: Twenty-eight articles discussing twenty-four studies were included. CYP engagement throughout the research cycle was limited. There were no observed differences in the reported presence of engagement, types of interventions or outcomes of engagement between studies engaging CYP or CYP and parents. Studies engaging CYP and parents contained limited information on how these relationships affected outcomes of engagement. Engagement was enabled primarily by the maintenance of resources and relationships among stakeholders. CONCLUSIONS: Although CYP engagement often influenced health intervention and implementation design, they are inconsistently engaged across the research cycle. It is unclear whether parental involvement enhances CYP engagement. Future research should consider reporting guidelines to clarify the level of CYP and/or parent engagement, and enhance CYP engagement by fostering synergistic and sustainable partnerships with key stakeholders. PATIENT OR PUBLIC CONTRIBUTION: A parent partner with codesign experience contributed to the creation of the research questions, screened titles, abstracts and full texts, helped with data extraction and provided feedback on the manuscript.

Leading by virtual interaction: an application of cultural-historical activity theory.

Introduction The pandemic spread of SARS-CoV-2, a novel, highly contagious and easily transmissible pathogen, has profoundly affected all aspects of human interaction. Guided by the need to reduce face-to-face contacts, medical organisations have rapidly shifted group activities to virtual platforms. Over 1 year into the pandemic, the necessity to maintain public health restrictions ensures that virtual meetings will be the norm for the foreseeable future.It has yet to be understood how virtual technologies shape healthcare and academic cultures, affect interactions, or influence strategic decisions and policies within these systems. Conclusion In this article, the authors reflect on the move from historically situated activity systems of team leadership in healthcare to ones that now exist in virtual formats. Cultural-historical activity theory (CHAT) is a framework that explains complex human actions, and how they unfold over time through interaction with mediational tools (eg, technology) and various people representing their own communities, roles and perceived divisions of labour. The authors use the lens of CHAT as a framework to understand the shifting dynamics at play and offer strategies for leaders to co-establish activity systems with team members to make goals of group activities explicit and to deliberately work toward them. Five specific strategies proposed are: (1) use software platforms that fit your needs and give voice to all attendees with technical support present in meetings; (2) converse explicitly about roles and emerging role fluidity during times of change and pandemic response; (3) co-construct something new intentionally; (4) engage in implementation science at this time; and (5) lead intentionally while honouring cultural norms and values. It is imperative that any changes, even the ones that are a part of the pandemic response, are made consistent with the core shared values of the medical community as this necessary new way of coming together is embraced with collective wisdom.

An interpretive phenomenological analysis of formative feedback in anesthesia training: the residents' perspective.

BACKGROUND: Consistent formative feedback is cornerstone to competency-by-design programs and evidence-based approaches to teaching and learning processes. There has been no published research investigating feedback from residents' perspectives. We explored the value residents place on feedback in routine operating room settings, their experiences, and understanding of the role of feedback in their training and developing professional identity. METHODS: Interpretive phenomenological analysis of residents' experiences with feedback received in clinical settings involved two focus groups with 14 anesthesia residents at two time points. Analysis was completed in the context of a teaching hospital adapting to new practices to align with nationally mandated clinical competencies. Focus group conversations were transcribed and interpreted through the lens of a social constructivist approach to learning as a dynamic inter- and intra-personal process, and evidence-based assessment standards set by the International Test Commission (ITC). RESULTS: Residents described high quality feedback as consistent, effortful, understanding of residents' thought processes, and containing actionable advice for improvement. These qualities of effective evaluation were equally imperative for informal and formal evaluations. Residents commented that highest quality feedback was received informally, and formal evaluations often lacked what they needed for their professional development. CONCLUSION: Residents have a deep sense of what promotes their learning. Structured feedback tools were seen positively, although the most important determinants of their impact were faculty feedback- and broader evaluation-skills and motivations for both formal and informal feedback loops.

Codesigning discharge communication interventions with healthcare providers, youth and parents for emergency practice settings: EDUCATE study protocol.

INTRODUCTION: Discharge communication is an important aspect of patient care but frequently has shortcomings in emergency departments (EDs). In a paediatric context, youth or parents with young children often leave the ED with minimal opportunity to ask questions or to ensure comprehension of important information. Strategies for improving discharge communication have primarily targeted patients and/or parents, although neither group has been engaged in intervention design or implementation. Furthermore, ED healthcare providers (HCPs), important actors in discharge communication practice, are rarely consulted regarding intervention design decisions. We will generate evidence to enhance discharge communication by engaging youth, parents and HCPs in the codesign of ED discharge communication strategies (EDUCATE) for asthma and minor head injury. METHODS AND ANALYSIS: This mixed methods study will take place at two academic paediatric EDs in Canada. The study will occur in two phases: (A) codesign and refinement of the intervention prototypes; and (B) usability testing of the prototypes. During the first phase, two codesign teams (one for each condition) will follow a series of structured design meetings based on the Behavior Change Wheel to develop the EDUCATE interventions. Each codesign team (composed of youth, parents, HCPs and study researchers) will collaborate to identify priority target behaviours and acceptable components to include in the interventions. During the second phase, we will conduct usability testing in two EDs with a group of youth, parents and HCPs to refine the interventions. Two cycles of usability testing will be conducted with intervention refinement occurring at the end of each cycle. ETHICS AND DISSEMINATION: Informed consent will be obtained from all participants. Ethics approval for this study has been obtained from the Research Ethics Board, IWK Health Centre. Results from this study will form the basis of a future effectiveness implementation trial. Key findings will be presented at national and international conferences and published within peer-reviewed journals.

Environmental scan and evaluation of best practices for online systematic review resources.

OBJECTIVE: Online training for systematic review methodology is an attractive option due to flexibility and limited availability of in-person instruction. Librarians often direct new reviewers to these online resources, so they should be knowledgeable about the variety of available resources. The objective for this project was to conduct an environmental scan of online systematic review training resources and evaluate those identified resources. METHODS: The authors systematically searched for electronic learning resources pertaining to systematic review methods. After screening for inclusion, we collected data about characteristics of training resources and assigned scores in the domains of (1) content, (2) design, (3) interactivity, and (4) usability by applying a previously published evaluation rubric for online instruction modules. We described the characteristics and scores for each training resource and compared performance across the domains. RESULTS: Twenty training resources were evaluated. Average overall score of online instructional resources was 61%. Online courses (n=7) averaged 73%, web modules (n=5) 64%, and videos (n=8) 48%. The top 5 highest scoring resources were in course or web module format, featured high interactivity, and required a longer (>5hrs) time commitment from users. CONCLUSION: This study revealed that resources include appropriate content but are less likely to adhere to principles of online training design and interactivity. Awareness of these resources will allow librarians to make informed recommendations for training based on patrons' needs. Future online systematic review training resources should use established best practices for e-learning to provide high-quality resources, regardless of format or user time commitment.

The Role of Metacognitive Reading Strategies, Metacognitive Study and Learning Strategies, and Behavioral Study and Learning Strategies in Predicting Academic Success in Students With and Without a History of Reading Difficulties.

We examined the self-reported use of reading, study, and learning strategies in university students with a history of reading difficulties (HRD; n = 77) and with no history of reading difficulties (NRD; n = 295). We examined both between-groups differences in strategy use and strategy use as a predictive measure of academic success. Participants completed online questionnaires regarding reading history and strategy use. GPA and frequency of use of academic support services were also obtained for all students. University students with HRD reported a different profile of strategy use than their NRD peers, and self-reported strategy use was differentially predictive of GPA for students with HRD and NRD. For students with HRD, the use of metacognitive reading strategies and the use of study aids predicted academic success. Implications for university student services providers are discussed.

Decision-Making Quality in Parents Considering Adenotonsillectomy or Tympanostomy Tube Insertion for Their Children.

Importance: Shared decision making is a process in which clinicians and patients make health care decisions in a collaborative manner using the most up-to-date evidence, while considering patient values and preferences. Shared decision making is thought to have a positive influence on the decision-making process in medicine. Objective: To describe the level of decisional conflict and decisional regret experienced by parents considering surgery for their children and to determine relations among decisional conflict, decisional regret, and shared decision making. Design, Setting, and Participants: A prospective cohort study was conducted at an academic pediatric otolaryngology clinic. Participants included 126 parents of children younger than 6 years who underwent consultation for adenotonsillectomy or tympanostomy tube insertion. Main Outcomes and Measures: Parent participants completed the Shared Decision Making Questionnaire-Parent version, Decisional Conflict Scale (DCS), and Decisional Regret Scale (DRS). Surgeons completed the Shared Decision Making Questionnaire-Physician version. Results: This study included 126 parents; 102 women (mean [SD] age, 33.2 [5.1] years) and 24 men (mean [SD] age, 35.6 [6.3] years). Overall, 34 parents (26%) reported clinically significant decisional conflict. Only 1 parent experienced moderate to strong decisional regret; 28 parents (43.7%) had mild decisional regret. Both parent and physician ratings of shared decision making were significantly negatively correlated with total DCS scores. Parent SDM-Q-9 and total DCS scores were significantly negatively correlated (rs[118] = -0.582; P < .001). Similarly, physician SDM-Q-Doc and total DCS scores were also significantly negatively correlated (rs[118] = -0.221; P = .04). Only parent ratings of shared decision making were significantly negatively correlated with total DRS scores (rs[63] = -0.254; P = .045). Those parents with clinically significant decisional conflict had significantly higher DRS scores (P = .02). Conclusions and Relevance: Many parents experienced significant decisional conflict when making decisions about their child's elective surgical treatment. Parents who perceived themselves as being more involved in the decision-making process reported less decisional conflict and decisional regret. Future research should explore the influence of decision quality on health outcomes and develop methods to improve shared decision making.

Decision aid prototype development for parents considering adenotonsillectomy for their children with sleep disordered breathing.

BACKGROUND: To describe the process involved in developing a decision aid prototype for parents considering adenotonsillectomy for their children with sleep disordered breathing. METHODS: A paper-based decision aid prototype was developed using the framework proposed by the International Patient Decision Aids Standards Collaborative. The decision aid focused on two main treatment options: watchful waiting and adenotonsillectomy. Usability was assessed with parents of pediatric patients and providers with qualitative content analysis of semi-structured interviews, which included open-ended user feedback. RESULTS: A steering committee composed of key stakeholders was assembled. A needs assessment was then performed, which confirmed the need for a decision support tool. A decision aid prototype was developed and modified based on semi-structured qualitative interviews and a scoping literature review. The prototype provided information on the condition, risk and benefits of treatments, and values clarification. The prototype underwent three cycles of accessibility, feasibility, and comprehensibility testing, incorporating feedback from all stakeholders to develop the final decision aid prototype. CONCLUSION: A standardized, iterative methodology was used to develop a decision aid prototype for parents considering adenotonsillectomy for their children with sleep disordered breathing. The decision aid prototype appeared feasible, acceptable and comprehensible, and may serve as an effective means of improving shared decision-making.

Shared decision-making in pediatric otolaryngology: Parent, physician and observational perspectives.

OBJECTIVE: To describe physician and parent behavior during pediatric otolaryngology surgical consultations, and to assess whether perceptions of shared decision-making and observed behavior are related. METHODS: Parents of 126 children less than 6-years of age who underwent consultation for adeontonsillectomy or tympanostomy tube insertion were prospectively enrolled. Parents completed the Shared Decision-Making Questionnaire-Patient version (SDM-Q-9), while surgeons completed the Shared Decision-Making Questionnaire-Physician version (SDM-Q-Doc) after the consultation. Visits were video-recorded and analyzed using the Roter Interaction Analysis System to quantify physician and parent involvement during the consultation. RESULTS: Perceptions of shared decision-making between parents (SDM-Q-9) and physicians (SDM-Q-Doc) were significantly positively correlated (p = 0.03). However, there was no correlation between parents' perceptions of shared decision-making and observations of physician and parent behavior/involvement (proportion of physician socioemotional talk, task-focused talk, or proportion of parent talk). Surgeons' perceptions of shared decision-making were correlated with physician task-focused talk and proportion of parent talk. CONCLUSIONS: Parents and physicians had similar perceptions of the degree of shared decision-making to be taking place during pediatric otolaryngology consultations. However, there was variability in the degree to which parents participated, and parent perceptions of shared decision-making were not correlated with actual observed involvement.

Parents' decisional conflict, self-determination and emotional experiences in pediatric otolaryngology: A prospective descriptive-comparative study.

OBJECTIVE: The aim of this study was to describe the level of decisional conflict experienced by parents considering surgery for their children and to determine if personal characteristics and emotional experiences vary as a function of whether or not parents experienced clinically significant levels of decisional conflict. METHODS: Sixty consecutive parents of children who underwent surgical consultation for elective otolaryngological procedures were prospectively enrolled. Participants completed the Decisional Conflict Scale, Basic Needs Satisfaction Scale, and the Positive and Negative Affect Schedule-Revised. RESULTS: Eight participants (13.3%) scored over 25 on the Decisional Conflict Scale, a previously defined cut-off indicating clinically significant decisional conflict. Parents who experienced significant decisional conflict felt less autonomous and less related or connected to others as compared to those who did not report significant decisional conflict. In addition, parents who experienced significant decisional conflict reported more negative emotions and fewer positive emotions during the surgical consultation visit. However, parents who reported significant decisional conflict did not report feeling less competent. CONCLUSIONS: Parental decision-making on whether their child should undergo elective pediatric otolaryngological surgery is a personal and emotional process. Parents' characteristics and experiences should be acknowledged and supported during the surgical consultation. Future research should aim to normalize the decision-making experience for parents, and to allow surgeons to be aware of the importance of decisional needs.

Normalized Apparent Diffusion Coefficient in the Prognostication of Patients with Glioblastoma Multiforme.

BACKGROUND: Glioblastoma multiforme (GBM) is known to have poor prognosis, with no available imaging marker that can predict survival at the time of diagnosis. Diffusion weighted images are used in characterisation of cellularity and necrosis of GBM. The purpose of this study was to assess whether pattern or degree of diffusion restriction could help in the prognostication of patients with GBM. MATERIAL AND METHODS: We retrospectively analyzed 84 consecutive patients with confirmed GBM on biopsy or resection. The study was approved by the institutional ethics committee. The total volume of the tumor and total volume of tumor showing restricted diffusion were calculated. The lowest Apparent Diffusion Coefficient (ADC) in the region of the tumor and in the contralateral Normal Appearing White Matter were calculated in order to calculate the nADC. Treatment and follow-up data in these patients were recorded. Multivariate analsysis was completed to determine significant correlations between different variables and the survival of these patients. RESULTS: Patient survival was significantly related to the age of the patient (p<0.0001; 95% CI-1.022-1.043) and the nADC value (p=0.014; 95% CI-0.269-0.860) in the tumor. The correlation coefficients of age and nADC with survival were -0.335 (p=0.002) and 0.390 (p<0.001), respectively. Kaplan Meier survival function, grouped by normalized Apparent Diffusion Coefficient cut off value of 0.75, was significant (p=0.007). CONCLUSION: The survival of patients with GBM had small, but significant, correlations with the patient's age and nADC within the tumor.

Understanding shared decision making in pediatric otolaryngology.

OBJECTIVE: The aim of this study was to describe the level of decisional conflict experienced by parents considering surgery for their children and to determine if decisional conflict and perceptions of shared decision making are related. STUDY DESIGN: Prospective cohort study. SETTING: Academic pediatric otolaryngology clinic. SUBJECTS AND METHODS: Sixty-five consecutive parents of children who underwent surgical consultation for elective otolaryngological procedures were prospectively enrolled. Participants completed the Shared Decision Making Questionnaire and the Decisional Conflict Scale. Surgeons completed the Shared Decision Making Questionnaire-Physician version. RESULTS: Eleven participants (16.9%) scored over 25 on the Decisional Conflict Scale, a previously defined clinical cutoff indicating significant decisional conflict. Parent years of education and parent ratings of shared decision making were significantly correlated with decisional conflict (positively and negatively correlated, respectively). A logistic regression indicated that shared decision making but not education predicted the presence of significant decisional conflict. Parent and physician ratings of shared decision making were not related, and there was no correlation between physician ratings of shared decision making and parental decisional conflict. CONCLUSIONS: Many parents experienced considerable decisional conflict when making decisions about their child's surgical treatment. Parents who perceived themselves as being more involved in the decision-making process reported less decisional conflict. Parents and physicians had different perceptions of shared decision making. Future research should develop and assess interventions to increase parents' involvement in decision making and explore the impact of significant decisional conflict on health outcomes.

The effectiveness of nurse-led outpatient referral triage decision making in pediatric otolaryngology.

OBJECTIVES: To assess the effectiveness of nurse-led triage of outpatient referrals in an academic pediatric otolaryngology practice. METHODS: Three hundred consecutive outpatient referrals were reviewed and triaged by two otolaryngology registered nurses and two attending pediatric otolaryngologists. The nurses received triage training. The referrals were triaged as 'routine' (to be seen within 2-3 months), 'semi-urgent' (to be seen within 6 weeks), or 'urgent' (to be seen within 2 weeks). Weighted Kappa statistics (correcting for chance agreement) were performed to assess for the degree of agreement. After the consultation visits, patient records were reviewed to determine whether any referrals had been inappropriately triaged by the nurses. RESULTS: Overall, there was substantial agreement between all raters. Specifically, weighted Kappa statistics were as follows: surgeon 1, nurse 1: 0.708; surgeon 1, nurse 2: 0.670; surgeon 2, nurse 1: 0.762; surgeon 2, nurse 2: 0.647; nurse 1, nurse 2: 0.756; and surgeon 1, surgeon 2: 0.784. Review of patient charts after consultation showed that no referrals were deemed to be inappropriately triaged and no urgent cases had been missed. CONCLUSIONS: Our model of nurse-led triage of outpatient referrals was found to be effective and safe. Similar systems may be considered in other areas of medicine as a viable and acceptable alternative to the traditional physician-led triage practice.

Spinal dural arteriovenous fistula: correlation between radiological and clinical findings.

OBJECT: The pathophysiology of spinal dural arteriovenous fistulas (SDAVFs) results in perimedullary venous congestion and in turn central cord congestion. Clinically, this presents with progressive neurological dysfunctions that, if diagnosed in a timely fashion, can be at least halted and in part reversed. In SDAVFs, imaging features on MRI and digital subtraction angiography (DSA) have not been studied in conjunction with clinical findings. The primary purpose of the present study was to test if severity of clinical presentation varies in relation to imaging. METHODS: This retrospective cohort study identified 12 patients treated for SDAVF at the authors' institution. The extent of venous congestion and cord edema was quantified by the number of vertebral levels shown to be affected on DSA and MRI. A modified Aminoff-Logue Scale (ALS) score was assigned at the time of diagnosis and again after definitive therapy. The patients were divided into one of two groups: those with venous congestion < 7 and ≥ 7 vertebral levels seen on DSA and MRI and with central cord edema < 6 and ≥ 6 levels. A t-test was used to assess for a difference in the presenting ALS score between the groups. RESULTS: Patients with ≥ 7 levels of venous congestion reported greater functional disability (DSA: p ≤ 0.001, Cohen's d = 0.509; and MRI: p ≤ 0.001, d = 0.632). Patients with a greater extent of cord edema also reported worse functional disability (p ≤ 0.001, d = 2.31). There was a strong linear correlation between the post- and pretreatment ALS scores (R(2) = 0.86) for those with successful interventions (n = 9). CONCLUSIONS: In patients with an SDAVF, the severity of the neurological dysfunction may be predicted by the extent of DSA- and MRI-documented venous congestion and cord edema. There was a strong positive relationship between initial and posttreatment neurological dysfunction.

An anatomically sound surgical simulation model for myringotomy and tympanostomy tube insertion.

OBJECTIVE: Myringotomy and tympanostomy tube insertion (MT) is a common surgical procedure. Although surgical simulation has proven to be an effective training tool, an anatomically sound simulation model for MT is lacking. We developed such a model and assessed its impact on the operating room performance of senior medical students. STUDY DESIGN: Prospective randomized trial. METHODS: A randomized single-blind controlled study of simulation training with the MT model versus no simulation training. Each participant was randomized to either the simulation model group or control group, after performing an initial MT procedure. Within two weeks of the first procedure, the students performed a second MT. All procedures were performed on real patients and rated with a Global Rating Scale by two attending otolaryngologists. Time to complete the MT was also recorded. RESULTS: Twenty-four senior medical students were enrolled. Control and intervention groups did not differ at baseline on their Global Rating Scale score or time to complete the MT procedure. Following simulation training, the study group received significantly higher scores (P=.005) and performed the MT procedure in significantly less time (P=.034). The control group did not improve their performance scores (P>.05) or the time to complete the procedure (P>.05). CONCLUSION: Our surgical simulation model shows promise for being a valuable teaching tool for MT for senior medical students. Such anatomically appropriate physical simulators may benefit teaching of junior trainees.