CJEM最新文献

Objectives: Most Canadian children (~ 80%) receive emergency care in general Emergency Departments (general EDs), which often lack pediatric readiness compared to Pediatric Emergency Departments (pediatric ED) and lead to poorer outcomes. Travelling on-site outreach simulation for Continuing Professional Development (CPD) can improve readiness but is resource-intensive. This study evaluates the acceptability and logistics of the Virtual Resus Room© (VRR), a free, online simulation platform for delivering pediatric outreach education remotely.

Methods: A multi-centre quasi-experimental simulation study was conducted with independently practicing physicians and nurses from 12 general EDs networked with two pediatric ED. Participants worked in teams, completing a 3.5-h VRR-CPD session with debriefing. Acceptability was assessed according to the Universal Theory of Acceptance and Use of Technology (UTAUT) framework using Simulation Effectiveness Tool Modified, Systems Usability Scale, Net Promoter Score (NPS) and open-text survey responses. Distance, time, and cost were compared to travelling outreach models.

Results: Thirty-seven participants from 9/12 general EDs completed 10 sessions over 10.5 h-more sessions than would be feasible traditionally. Participants and facilitators reported high educational value, strong ease-of-use, and above-average NPS (60 and 71). Feedback praised accessibility and high-quality debriefs, but noted challenges with internet reliability, simultaneous conversations, and decreased allied health engagement from platform constraints. VRR-CPD simulation had significant distance, cost ($668.50 vs $929.06/session) and time savings (210 vs 423 min).

Conclusions: VRR-based virtual simulation is a feasible, accessible, and resource-efficient continuing professional development tool. VRR-CPD can aid pediatric readiness efforts with more broader and equitable reach than traditional models, especially when paired with hybrid education approaches.

Introduction: Management of febrile neutropenia in previously healthy, presumed immunocompetent children varies. Unnecessary treatment impacts the patients, families, and the healthcare system. With guidance from a Canadian Paediatric Society Practice Point, most well-appearing children with a first episode of febrile neutropenia can be managed with reduced exposure to antibiotics and close outpatient follow-up. The aim of this initiative was to safely reduce antibiotic use in this low-risk population presenting to the emergency department (ED).

Methods: A multidisciplinary team designed a quality improvement (QI) initiative. From July 2022 to July 2024, treatment with antibiotics was classified as indicated or non-indicated according to guidance from the Practice Point. Interventions involved guideline dissemination, provider education, and point-of-care tools to facilitate clinical decision-making and follow-up. Outcome measures included the proportion of children receiving antibiotics, hospital admission, and appropriate laboratory follow-up. Re-presentation to ED and missed serious bacterial infections were monitored as balancing measures. Analysis of the primary outcome was by statistical process control.

Results: Three hundred and ninety-eight (398) children with febrile neutropenia were included. The proportion of non-indicated antibiotics was 6.7% at baseline. Statistical process control analysis of the G-chart demonstrated special cause variation with 97 consecutive cases occurring without error (non-indicated antibiotics). Following the occurrence of special cause variation until the end of the study, only 1.6% of children received non-indicated antibiotics. There was no increase in re-presentations to ED (9% vs 8%; p = 0.65) nor missed serious bacterial infections (0% vs 0%).

Conclusions: Quality improvement methodology can facilitate the timely adoption of best practices to align local clinical care with new national guidelines. Implementation of the national guideline allowed low-risk children with febrile neutropenia to avoid overtreatment.

Objectives: Sepsis is a common and clinically challenging life-threatening condition affecting children. Well-designed guidelines integrated into quality improvement initiatives reduce pediatric sepsis mortality and hospital length of stay. Our objective was to evaluate the quality of Canadian pediatric sepsis guidelines for children presenting to emergency departments (ED) and evaluate their consistency and concordance with the Surviving Sepsis guidelines (international reference standard).

Methods: We contacted all 15 Canadian pediatric hospitals and national organizations to obtain guidelines. Guidelines were included if they contained at least one recommendation on detection or management of pediatric sepsis in the ED. Two independent reviewers applied the AGREE-II tool to evaluate guideline quality (methodologic rigor). Quality was classified as high, moderate, or low based on published definitions. For each of the 12 ED-relevant recommendations from the reference standard, we calculated the percentage of all Canadian guidelines that provided the same recommendation (consistency). For each individual Canadian guideline, we calculated the percentage of the 12 recommendations that were the same as the reference standard (concordance).

Results: Nine guidelines were included. Guidelines were presented as pathway/algorithm, order set, narrative, or a combination of formats. Most institutional guidelines were of low quality, and a single national guideline was classified as high quality. Overall, guidelines were highly consistent across most recommendations of the reference standard, except for fluid bolus content (balanced vs normal saline). Similarly, individual guidelines were highly concordant with the reference standard, with only one low-quality guideline having a concordance of less than 80%.

Conclusion: The quality of Canadian institutional guidelines is low in terms of methodological development; however, recommendations in these guidelines remain generally consistent with an international reference standard, though key areas of inconsistency exist. Future efforts should focus on regularly reviewing and updating the robust national guideline that can be adapted to local institutional needs.

Objectives: To address crowding, our pediatric emergency department (ED) implemented a triage nurse-led protocol to redirect non-urgent patients to external pediatric clinics, other healthcare providers, family physicians, or home. This study aimed to identify the proportion of redirected children who returned to the ED and identify predictors of return.

Methods: We conducted a health records review study of children under 18 years redirected from the ED of a tertiary pediatric hospital in Montreal, Canada. A random sample of 150 return visits and 300 controls was selected for a nested case-control study. The primary outcome was a return visit to the ED within 7 days. Potential predictors included demographic information, disease characteristics, triage level, and initial orientation. We calculated the proportion of return visits and performed univariate and multivariable analyses of identified predictors.

Results: Between September 2023 and August 2024, 80,221 children were triaged, of whom 6,556 (8.2%) were redirected. Within 7 days, 372 (5.7%) returned. Among the 150 reviewed return visits, 127 (85%) were related to the initial complaint: 64 (43%) were due to persistent symptoms, 49 (33%) to clinical deterioration, 6 (4%) were sent back by a physician, and 5 (3%) were for new symptoms. Seven patients (4.7%) required hospitalization on their return visit. Predictors associated with a lower probability of return included ear, nose, throat, and dental complaints, as well as redirection to specialized or pediatric clinics.

Conclusions: Approximately, 6% of redirected children returned to the ED within 7 days, most often for persistent or worsening symptoms. Identifying predictors of return visits provides evidence to refine redirection guidelines and enhance the safety and effectiveness of triage nurse-led redirection strategies.

Purpose: The primary objective is to evaluate associations between emergency department (ED) total length of stay in Alberta and multiple patient-, visit-, and facility-level factors known to contribute to overcrowding and healthcare inefficiencies. This work aims to inform ongoing efforts to optimize ED performance and patient flow and, to our knowledge, is the largest population-based Canadian study examining associations with ED length of stay at multiple levels.

Methods: We conducted a cross-sectional study of 587,419 ED visits from 14 facilities in Alberta between May 2022 and March 2023 using administrative health data from Alberta Health Services, linked to the National Ambulatory Care Reporting System. Multivariable negative binomial regression was used to examine associations between ED length of stay and patient-, visit-, and facility-level characteristics. Analyses were stratified by patient disposition (admitted, discharged, or other).

Results: Older age, greater material or social deprivation, and any mode of emergency medical services transport were associated with longer ED length of stay across all disposition categories. Higher hospital inpatient occupancy rate and a greater number of emergency inpatients were associated with increased length of stay, particularly for admitted patients. Higher nurse staffing rates were associated with shorter length of stay, though this association disappeared when accounting for random differences between facilities. Higher patient continuity to physician was associated with a lower length of stay, suggesting a potential benefit of primary care integration.

Conclusions: ED length of stay is associated with modifiable factors, including hospital capacity constraints, hours worked per nurse, and healthcare access inequities. Addressing hospital occupancy, optimizing staffing, and improving care coordination across the patient trajectory-such as between the ED, inpatient units, and post-discharge services-may enhance ED efficiency and reduce prolonged stays. Our findings align with established frameworks describing ED overcrowding and support targeted, system-level interventions to improve the efficiency of emergency care.