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To validate the two-factor structure (i.e., cognitive and somatic) of the Health and Behaviour Inventory (HBI), a widely used post-concussive symptom (PCS) rating scale, through factor analyses using bifactor and correlated factor models and by examining measurement invariance (MI).
PCS ratings were obtained from children aged 8–16.99 years, who presented to the emergency department with concussion (n = 565) or orthopedic injury (OI) (n = 289), and their parents, at 10-days, 3-months, and 6-months post-injury. Item-level HBI ratings were analyzed separately for parents and children using exploratory and confirmatory factor analyses (CFAs). Bifactor and correlated models were compared using various fit indices and tested for MI across time post-injury, raters (parent vs. child), and groups (concussion vs. OI).
CFAs showed good fit for both a three-factor bifactor model, consisting of a general factor with two subfactors (i.e., cognitive and somatic), and a correlated two-factor model with cognitive and somatic factors, at all time points for both raters. Some results suggested the possibility of a third factor involving fatigue. All models demonstrated strict invariance across raters and time. Group comparisons showed at least strong or strict invariance.
The findings support the two symptom dimensions measured by the HBI. The three-factor bifactor model showed the best fit, suggesting that ratings on the HBI also can be captured by a general factor. Both correlated and bifactor models showed substantial MI. The results provide further validation of the HBI, supporting its use in childhood concussion research and clinical practice.
Somatization is a common phenomenon that can severely complicate youths’ functioning and health. The burden of somatization on pediatric acute care settings is currently unclear; better understanding it may address challenges clinicians experience in effectively caring for somatizing patients. In this study, we estimate the prevalence of somatization in a pediatric emergency department (ED).
We conducted a retrospective cross-sectional study of visits for non-critical, non-mental health-related concerns (n = 150) to a quaternary-level pediatric ED between July 2016 and August 2017. Demographic and clinical visit details were collected through chart review and used by two reviewing clinicians to classify whether each visit had a “probable,” “unclear” (possible), or “unlikely” somatizing component.
Approximately 3.33% (n = 5) of youth displayed probable somatization, and an additional 13.33% (n = 20) possibly experienced a somatizing component but require additional psychosocial and visit documentation to be certain. Longer symptom duration and multiple negative diagnostic tests were associated with a higher likelihood of either probable or possible somatization.
A considerable proportion of non-mental health-related visits may involve a somatizing component, indicating the burden of mental health concerns on the ED may be underestimated. A higher index of suspicion for the possibility of somatization may support clinicians in managing somatizing patients.
Numerous studies reported on the frequency of, and factors associated with inappropriate or unnecessary emergency department (ED) visits using clinician judgment as the gold standard of appropriateness. This study evaluated the reliability of clinician judgment for assessing appropriateness of pediatric ED visit.
We conducted a retrospective cohort study comparing 3 clinicians’ determination of ED visit appropriateness with and without guidance from a three-question structured algorithm. We used a cohort of scheduled ED return visits deemed appropriate by the index treating clinician between May 1, 2012, and April 30, 2013. We measured the level of agreement among three clinician investigators with and without use of the structured algorithm.
A total of 207 scheduled ED return visits were reviewed by the primary clinician reviewer who agreed with the index treating clinician for 79/207 visits (38.2%). Among a random subset of 90 return visits reviewed by all three clinicians, agreement was 67% with a Fleiss’ Kappa of 0.30 (0.17–0.44). Using a three-question algorithm based on objective criteria, agreement with the index treating provider increased to 115/207 (55.6%).
Although an important contributor to pediatric ED overcrowding, unnecessary or inappropriate visits are difficult to identify. We demonstrated poor reliability of clinician judgment to determine appropriateness of ED return visits, likely due to variability in clinical decision-making and risk-tolerance, social and systems factors impacting access and use of health care. We recommend that future studies evaluating the appropriateness of ED use standardized, objective criteria rather than clinician judgment alone.
To determine the incidence, risk, and timing of mortality (unnatural and natural causes) among youth seen in a pediatric emergency department (ED) for mental health concerns, compared with matched non–mental health ED controls.
This was a retrospective cohort study conducted at a quaternary pediatric ED in British Columbia. All visits for a mental health related condition between July 1st, 2005, and June 30th, 2015, were matched on age, sex, triage acuity, socioeconomic status, and year of visit to a non–mental health control visit. Mortality outcomes were obtained from vital statistics data through December 31st, 2016 (cumulative follow-up 74,390 person-years).
Among all cases in our study, including 6,210 youth seen for mental health concerns and 6,210 matched controls, a total of 13 died of suicide (7.5/100,000 person-years) and 33 died of suicide or indeterminate causes (44/100,000 person-years). All-cause mortality was significantly lower among mental health presentations (121.3/100,000 v. 214.5/100,000 person-years; hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.37–0.78). The median time from initial emergency visit to suicide was 5.2 years (interquartile range, 4.2–7.3). Among mental health related visits, risk of death by suicide or indeterminate cause was three-fold that of matched controls (HR, 3.05 95%CI, 1.37–6.77).
While youth seeking emergency mental health care are at increased risk of death by unnatural causes, their overall mortality risk is lower than non–mental health controls. The protracted duration from initial presentation to suicide highlights the need for long-term surveillance and preventative care for youth seen in the ED for all mental health concerns.
Our objectives were to describe disposition decisions and emergency department return (EDR) rates following a clinical decision unit (CDU) stay; and to determine changes to short stay (<48 hour) hospitalization rates after CDU implementation.
We conducted a retrospective cohort study of pediatric emergency department (PED) visits with a CDU stay from January 1 to December 31, 2015. Health records data were extracted onto standardized online forms, then used to determine disposition and 7-day EDR rates. Two trained investigators blindly reviewed EDR visits to determine if they were related to the index CDU stay. We compared short stay inpatient admission rates (i.e., hospital length of stay <48 hours) in 2013 and 2015, before and after CDU implementation.
Of 1696 index CDU stays, 1503 (89%) were discharged, and 139 discharged patients (9.2%) had ≥1 clinically-related EDR. Median (IQR) CDU length of stay (LOS) was 4.4 hours (2.7-7.8) and total PED LOS (including CDU) was 7.8 hours (5.4-12.0). Asthma represented 31% of cases. Short stay hospitalization rate decreased from 3.62% in 2013 to 3.23% in 2015 (difference=0.39%; 95% CI=0.15-0.63; p=0.001).
Most CDU patients were discharged, but 9% had a clinically-related ED revisit. CDU implementation was associated with a small but significant reduction in short stay hospitalization.
To evaluate the psychometric properties of HEARTSMAP, an emergency psychosocial assessment and management tool, and its impact on patient care and flow measures.
We conducted the study in two phases: first validating the tool using extracted information from a retrospective cohort, then evaluating implementation on a prospective cohort of youth presenting with mental health complaints to a tertiary Pediatric Emergency Department (PED). In phase 1, six PED clinicians applied HEARTSMAP to extracted narratives and we calculated inter-rater agreement for referral recommendations using Cohen’s Kappa and the sensitivity and specificity for identifying youth requiring psychiatric consultation and hospitalization. In phase 2, PED clinicians prospectively used HEARTSMAP and we assessed the impact of the tool’s implementation on patient-related outcomes and Emergency department (ED) flow measures.
We found substantial agreement (κ=0.7) for cases requiring emergent psychiatric consultation and moderate agreement for cases requiring community urgent and non-urgent follow-up (κ=0.4 each). The sensitivity was 76% (95%CI: 63%, 90%) and specificity was 65% (95%CI: 55%, 71%) using retrospective cases. During pilot implementation, 62 patients received HEARTSMAP assessments: 46 (74%) of HEARTSMAP assessments triggered a recommendation for ED psychiatry assessment, 39 (63%) were evaluated by psychiatry and 13 (21%) were admitted. At follow-up, all patients with HEARTSMAP’s triggered recommendations had accessed community resources. For those hospitalized for further psychiatric care at their index or return visit within 30 days, 100% were initially identified by HEARTSMAP at the index visit as requiring ED psychiatric consultation.
HEARTSMAP has strong reliability, and when applied prospectively is a safe and effective management tool.
Return visits to the emergency department (RTED) for the same clinical complaint occur in 2.7% to 8.1% of children presenting to pediatric emergency departments (PEDs). Most studies examining RTEDs have focused solely on PEDs and do not capture children returning to other local emergency departments (EDs). Our objective was to measure the frequency and characterize the directional pattern of RTED to any of 18 EDs serving a large geographic area for children initially evaluated at a PED.
We conducted a retrospective cohort study of all visits to a referral centre PED between August 2012 and August 2013. We compared demographic variables between children with and without an RTED, measures of flow and disposition outcomes between the initial (index) visit and RTED, and between RTED to the original PED versus to other EDs in the community.
Among all PED visits, 7.6% had an RTED within 7 days, of which 13% were to a facility other than the original PED. Children with an RTED had higher acuity and longer length of stay on their index visit. They were also more likely to be admitted on a subsequent visit than the overall PED population. RTED to the original PED had a longer waiting time (WT), length of stay, and more frequently resulted in hospitalization than RTED to a general ED.
A significant proportion of RTED occur at a site other than where the original ED visit occurred. Examining RTED to and from only PEDs underestimates its burden on emergency health services.
Emergency department (ED) crowding is a significant problem in Canada and has been associated with decreased quality of care in general and pediatric emergency departments (PEDs). Although boarding of admitted patients in the ED is the main contributor to adult ED overcrowding, factors involved in PED crowding may be different. The objective of this study was to report the trend in PED services use and to document the degree of overcrowding experienced in a Canadian PED.
A retrospective cohort study was conducted using administrative data from a tertiary care PED from 2002 to 2011. The primary outcome was PED use (total volume of visits and case severity per triage levels using the Canadian Triage and Acuity Scale [CTAS] score and admissions). Secondary outcomes included measures of PED overcrowding, such as rates of patients leaving without being seen (LWBS) and length of stay (LOS).
Total volumes increased by 30% over the 10-year study period, whereas hospitalizations remained stable at approximately 10%. Trends in CTAS levels did not indicate meaningful changes in the severity of cases treated at our PED. LWBS proportions among CTAS 3, CTAS 4, and CTAS 5 groups and LOS for all CTAS groups progressively and statistically increased from year to year.
Over the course of the study period, there was a substantial increase in PED visits,which likely contributed to the worsening markers of PED flow outcomes. Further study into the effects of PED crowding on patient outcomes is warranted.
To determine the willingness of parents of children visiting a pediatric emergency department to have a physician assistant (PA) assess and treat their child and the waiting time reduction sufficient for them to choose to receive treatment by a PA rather than wait for a physician.
After describing the training and scope of practice of PAs, we asked caregivers of children triaged as urgent to nonurgent if they would be willing to have their child assessed and treated by a PA on that visit: definitely, maybe, or never. We also asked the minimum amount of waiting time reduction they would want to see before choosing to receive treatment by a PA rather than wait for a physician.
We approached 320 eligible subjects, and 273 (85.3%) consented to participate. Regarding whether they would be willing to have their child receive treatment by a PA, 140 (51.3%) respondents answered definitely, 107 (39.2%) said maybe, and 26 (9.2%) said never. Most respondents (64.1%) would choose to have their child seen by a PA instead of waiting for a physician if the waiting time reduction were at least 60 minutes (median 60 minutes [interquartile range 60 minutes]). Respondents' perception of the severity of their child's condition was associated with unwillingness to receive treatment by a PA, whereas child's age, presenting complaint, and actual waiting time were not.
Only a small minority of parents of children visiting a pediatric emergency department for urgent to nonurgent issues are unwilling to have their child treated by PAs.
To define the range of clinical conditions Canadian emergency pediatricians consider appropriate formanagement by physician assistants (PAs) and the degree of autonomy PAs should have in the pediatric emergency department (PED).
We conducted a cross–sectional, pan-Canadian survey using electronic questionnaire technology: the Active Campaign Survey tool. We targeted PED physicians using the Pediatric Emergency Research Canada (PERC) network database (N = 297). Three outcome measures were assessed: demographic information, familiarity with PAs, and PA clinical roles in the PED. The level of PA involvement was assessed for 57 common nonemergent clinical conditions.
Of 297 physicians, 152 completed the survey, for a response rate of 51.2%. None of the 57 clinical categories achieved at least 85% agreement regarding PA management without direct physician involvement. Twenty-four clinical conditions had ≥ 15% agreement that any PA involvement would be inappropriate. For the remaining 33 clinical conditions, more than 85% of respondents felt that PA could appropriately manage but were divided between requiring direct and only indirect physician supervision. Respondents' selection of the number of conditions felt to be appropriate for PA involvement varied between the size of the emergency department (ED) in which they work (larger EDs 87.7–89.1% v. smaller EDs 74.2%) and familiarity with the clinical work of PAs in the ED (90.5–91.5% v. 82.2–84.7%).
This national survey of Canadian PED physicians suggests that they feel PAs could help care for a large number of nonemergent clinical cases coming to the PED, but these clinical encounters would have to be directly supervised by a physician.
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